When can your cashless claim get rejected and what next?

When you buy health insurance, most companies promise a cashless claim at the hospital. With a cashless claim, the insured can be admitted to a Network hospital without any deposit at check-in and has to bear no medical bills after the commencement of the treatment.

The magical insurance card, submitted at the time of the treatment does the trick. The hospital contacts the insurer and the company settles the bills directly. The insured just needs to take care of the overhead expenses, like extra services if any is availed.

But sometimes this cashless claim is declined. Let us examine the scenarios and see the solution to them.

When you check in a Non-Network Hospital

Every insurance company has a list of network hospitals in particular pin codes. This means that insurer has a tie-up with these hospitals and you can avail a cashless treatment there.

However if in case of an emergency or any other situation, if one decides to get admitted to another non-network hospital, the bills have to be cleared initially by the insurer and then one can go for a reimbursement claim (Explained below)

If the hospitalization is due to a pre-existing conditions in the initial years of the policy

A pre-existing condition like diabetes may not be covered in the insurance policy for 3-4 years. So if a person with advanced diabetes is admitted to the hospital because of stroke, then one may not receive the cashless claim, as it is a condition arising from diabetes. In such a situation, it is important to read the policy details carefully and know the time after which pre-existing conditions are covered.

Non-Disclosure or Incorrect mention of facts during policy purchase or claims

A cashless claim can be rejected, in the event of a discrepancy in details entered while buying or claiming the policy. This can be non-disclosures, partial disclosures and wrong disclosures of significant facts such as age, nature of the occupation, income, existing insurance policies, major ailments or pre-existing medical conditions. Coverage is offered based on the information provided by the insured on the proposal form and hence any gap between what is declared and the reality at the time of filing claims can be a reason for rejection. So, always answer all questions honestly when you apply for a health policy.

Superfluous Expenditure on a treatment or service from the hospital

Sometimes, a hospital, in its quest to generate maximum revenue, may perform medical procedures which may not be necessary, on patients covered by a medical insurance policy. The policyholder is also relaxed about it as he mistakenly assumes the money will be paid by the insurance company.

What to do when your Cashless Claim Gets Rejected

If a cashless claim is rejected, for any reasons, then one can still be eligible for a reimbursement claim. In such a situation,

  1. Immediately notify the insurance company or the Third Party Aggregator (TPA) about the hospitalization and rejection of the claim.
  2. Clear your hospital bills upon discharge.
  3. Fill and sign the Reimbursement claim form of the insurer. You can find it on their website, under the claims tab.
  4. Submit the claim form along with all the hospital documents, at a branch of the insurance company or TPA near you.
  5. Track the progress of your claim and stay in touch with the insurance company.  

In order to avoid any of the above situations, be sure to understand your policy document clearly. It is also advised to compare all the plans out there. Visit Turtlemint to find a policy, which suits your needs.

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Misselling in health insurance and how to avoid being a victim

Insurance understanding and knowledge is not easy. The fine print which accompanies any policy is tricky and it is tedious for a layman to understand and comprehend it. The language is very convoluted and boring to read. So, a lot of buyers, fail to understand the policy and settle for an unsuitable one. Insurance agents capitalize on this impulsive nature of the buyer. They end up mis-selling the policy for immediate gains. This leads to expectation mis-match.

What does Mis selling a policy include?

Mis selling is selling a policy by giving a wrong picture of the policy. It may include, giving wrong information, giving unrealistic information, and not giving full details of the product.

What is IRDA doing to Prevent Mis selling?

In the past few months the Insurance Regulatory Development Authority has taken several steps to increase transparency and further the policyholders’ cause. They have made laws against mis-selling strict and take action against fraudulent cases.

You healthcare policy comes with a free look period. This means that a policyholder can return the policy within 30 days from the date of receipt if terms and conditions are not agreeable or suitable.

How can you Avoid being a Victim of Mis-selling?

Know the track record of your insurance agent and ask questions clearly

Insurance agents usually push plans which fetch them high rates of commissions. They capitalize on the ignorance of the regular customers and latch onto them plans which may not be very useful for them. Often, after the policy is sold, they magically disappear and do not help in claim processing as promised. To avoid such a situation, make sure you go to a reliable agent with a good track record. Be patient and ask him/her all the questions.

Understand all Policy Exclusion thoroughly before settling down for one

Whenever a person buys an insurance plan, he/she is more focussed on the price comparison between premiums and the sum insured. They miss the limits, hospitals covered, diseases covered and the sub clauses and their wordings. Make sure you know what you are looking for, double check to see if those particular conditions are included or not.

Understand the product well and refrain from under or over investing for Health Insurance

The lack of awareness of the available insurance products can be detrimental. As a buyer you need to know the actual value of the product ‘for you’.  If are in your 20s, with no liabilities, then you can start with an insurance cover which is lower.

Be on a lookout for Limits and Co-pays if Any

Many health insurance policies have room rent capping which means that you are eligible to claim expenses only up to a room costing below this capping.

For instance, you room capping is Rs 4000/day and you opt for a room worth Rs 7000/day, you will have to bear the additional expenses on your own. Room capping may not only be for room rent, but other facilities as well which come with it.

Also, a number of policies, especially as you age, come with clauses of co-pay for certain parts of the claim. For instance, if your policy has a co-pay of 50% for a cardiovascular surgical procedure, you will have to bear half the expense.  Look out for words like limits, deductible, co-pay in the policy and especially the terms and conditions associated with each of them.

Avoid having unrealistic prediction of returns

A lot of buyers are misguided, about the terms and conditions of a policy. They are shown unrealistic predictions of the returns. This tactic is to lure the customer into getting the policy. Whenever you decide to buy a particular company’s policy, make sure to check their claim settlement ratio and the reviews provided by other users.

Compare all policies out there and find the best one to suit your needs

Whenever you are opting for an insurance policy, you need to evaluate all the options out there. There are policies which will suit your need. You need to opt for one which fits your requirements. At Turtlemint, you can find all the policies and compare them at a glance to find the one for you. We decode the fine print, and highlight all the key factors to make decision making simple and clear.

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Be Insurance Smart 🙂