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Know Your Health Policy
Claim-related grievances often corner the largest share when it comes to health insurance complaints lodged with the Insurance Regulatory and Development Authority (IRDA). In 2012-13, delay in settlement, claim rejection and partial claim settlement made up nearly 38% of complaints received by the insurance regulator. The reasons could vary from non-disclosure of pre-existing illnesses by the policyholder and different interpretation of policy wordings to wilful rejection by the insurer or the third party administrator.
Exclusions
In simple terms, this refers to expenses that the insurer will not pay for. Lack of understanding of what is not covered is one of the key causes for disputes. For instance, coverage of preexisting illness is often the bone of contention between the insurer and the policyholder. Most insurance companies cover pre-existing ailments only after a waiting period of four years.
Any ailment or condition that was diagnosed or treated within 48 months prior to the policy being purchased is considered to be a pre-existing disease. Such claims are not entertained if the policyholder was aware of the disease.
The dispute usually arises when there is no clarity on the date of inception of the disease or on the grounds that it was not disclosed by the policy-holder.
Going forward, Irda’s list of 199 items — explicitly indicating their admissibility or otherwise — released as part of standardisation norms could play a role in reducing the ambiguity.
Partial Settlement
Many policyholders’ grievances pertain to insurers reimbursing only a part of the hospitalisation expenses actually incurred. Insurers, on their part, point to policy wordings, which impose caps, termed sub-limits on certain expenses. For instance, many health insurers now restrict cataract surgery cost to . 24,000-25,000. If your expenses exceed this limit, you will have to pay for the balance out of your own pocket. Likewise, room rent payable by the insurer could be limited to 1% of the sum insured.
Remember, when you choose a hospital room, all the other charges, including doctor’s fees, are linked to it. A higher room rent would mean that other expenses would be proportionately higher. Therefore, do your homework while choosing the room in a hospital, wherever possible.
The insurer’s decision on partial settlement could also be based on the reasonability clause, which states that only those expenses that are ‘reasonably and necessarily’ incurred will be reimbursed.
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