Your health insurer may not settle claims in full: Here’s why

When you pay your health insurance premiums regularly and claim cashless settlement or reimbursement as and when you take treatment, you expect to get the entire amount you spend on your hospitalisation bills.

However, that may not be the case as insurers clear only a part of claims that you make — by citing a few key clauses in your health insurance policy.

It is important for you, as a policyholder, to know these key parts of your policy so that you stay prepared to fork out a part of the medical bill and not be caught unaware at the time of medical bill settlement. The amounts can be quite significant at times, especially in the case of senior citizens.

Here’s more on these key policy clauses.

Paying from your pocket

In some policies, especially for those involving senior citizens, there may be a co-pay clause. So, you need to pay a portion of the bill for certain medical treatments. The percentage is usually set in the insurance policy’s terms and conditions section and is made known to the policyholder. Some, insurance policies have a 10-20 per cent co-pay requirement. Thus, if you run up a bill for ₹1 lakh at the hospital, the insurance company will settle ₹90,000 (less any consumables used) and you will have to pay the balance ₹10,000 from your savings if the co-pay requirement is 10 per cent.

Group insurance covers provided by employers also have co-pay clauses at times for specific ailments and in the case of senior citizens.

Then, consumables — syringes, needles, cotton, gauze swabs, catheters, PPE kits, gloves, masks, sanitisers and so on — are generally not covered under regular insurance policies. Before the pandemic, consumables used to account for about 5 per cent of the total medical bill. But, subsequently, the proportion has risen to 20 per cent levels and there have been instances of such costs touching 30-40 per cent of the hospitalisation cost. Administrative, housekeeping and room services are also not covered in most policies.

HDFC Ergo, Tata AIG, Care Health and Niva Bupa offer add-on consumables covers or riders to take care of such expenses, in lieu of slightly higher premiums.

Cap on settlement

Some insurance companies link the settlement amount to the room rent amount sanctioned in their health insurance covers. Many health insurers have limits on hospital room rents that policyholders can avail of. The rate could be an absolute figure, say, ₹5,000 or ₹10,000 per day, or a percentage of sum assured, usually 1 per cent. While health covers of most private insurance companies, especially the recently rolled out ones, do not have any cap on room rents, some old public-sector insurers such as United India Insurance and New India Assurance have such ceilings.

Thus, the maximum limit you can avail of as room rent is ₹5,000 per day. If you get admitted in a hospital that charges a higher amount for the room, say, ₹15,000 a day, you may have to pay the remaining sum from your pocket. Also, all bills are pegged to the room rent. If instead of ₹5,000 that you are allowed, you choose to get admitted in a hospital that charges ₹10,000, or 100 per cent more, your total bill settlement allowed would also be lower. In the above case you will have only half of your total medical bill settled by the insurer.

When you take a health insurance policy, you must ensure that there are no caps on daily room rents.

One key aspect you must take note of is that you must have the list of network hospitals handy with you, so you can get into the right hospitals even during emergencies.

You must be careful to avoid blacklisted hospitals, the list of which would be available in your insurer’s website or app. If you choose to get admitted in such hospitals, your entire claim may be rejected.

Some procedures do not require 24-hour hospitalisation, such as day-care surgeries. Then there are also sub-limits on payouts for specific treatments.

So cataract removal, mid-ear operation, dialysis, sinus surgery, knee replacement, hernia removal and the like usually have an upper limit on the amount that is sanctioned, irrespective of the actual costs incurred. For example, some insurers allow only ₹25,000- 30,000 per eye for cataract removal. Any higher amount charged would have to be borne by you.

It is good to have a comprehensive health insurance cover with relevant riders. But you must always have a medical corpus (as a part of your overall emergency fund) that is sufficient enough to cover what is not settled by the health insurance company.

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