Know When Your Entire Health Insurance Claim Amount Will Not Be Settled
Updated On Jan 22, 2021
People buy health insurance to support themselves financially during a medical emergency. Health insurance policyholders believe that be it by cashless claim or reimbursement claim, they will get all their medical needs covered without paying even a single penny. However, that does not happen every time.
You must have heard of many cases where the policyholder had to pay for a few expenses from their own pocket. Why? Simply because their health insurance company did not offer to pay for all expenses! But, how did it take place? Do health insurance companies have some disallowances as well or not cover everything? Well, let’s find out!
Reasons for Non-Settlement of Complete Health Insurance Claims
Below mentioned is the list of popular reasons, the presence of which make it difficult for the health insurance company to cover everything:
1. Co-payment: The presence of the co-payment clause or the cost-sharing provision impacts the way health insurance services are availed. Also, keep in mind that a smaller percentage such as 10% is easy to manage. However, a higher percentage of co-payment can result in the insured paying a significant amount (even in Lakhs) from their own pocket.
It is advisable to thoroughly check the policy for co-pay level and the insured’s comfort before making a purchase.
2. Room Rent Restrictions: Having a health insurance policy with a very low room rent limit can lead you to non-settlement of the entire claim amount. Remember, by not paying attention to room rent restrictions or room category restrictions mentioned in the policy, you can easily invite disappointment during hospital admission as well as payment for room rent.
Based on the sum insured amount and choice of hospital, one may end up paying a massive amount due to room rent/category restriction in the policy. Therefore, it is necessary to emphasize room rent restrictions during policy purchase.
3. Geography Restrictions: Some health insurance policies come with geography-based pricing. This pricing is done based on the customer's location. For instance, customers living in metros pay a higher premium than those who live in smaller cities and towns. Policyholders living in small towns, but looking for treatment in big cities might have to face out of pocket expenses.
4. Policy Sub-limits: Sub-limits may be present in a policy for specific benefits such as a limit for AYUSH treatment. In some health insurance policies, even pre and post hospitalization expenses are capped at 10% of the inpatient claim. It is important to check the policy for any sub-limit before making a purchase to avoid last-minute issues and inconveniences.
5. Procedure Sub-limits: Common surgical treatments such as hernias, cataracts, and others if covered in a health insurance policy have limits much lower than the policy limit. In case, your bill comes more than the limit of the procedure, you will have to bear the difference in expenses.
6. Limitation of Expenses: Some health insurance policies are restrictive in nature that put limits on professional charges and other medical expenses. It is significant to note that this feature is quite uncommon and comes in a few retail plans.
7. Consumables: Consumable charges consume 3 to 6% of a hospital bill. In case a policy does not cover these costs, there is no option for the consumer, but to bear the expenses on their own.
Also, Read
Health Insurance for NRIs – A Purchase Guide
How to Make a Complaint Against Your Health Insurance Company?
Final Words
While the presence of certain features in a health insurance policy may cause inconvenience to customers, these charges do not pose a major burden on one’s pocket.
The best way to avoid even the slightest of inconvenience is to read the policy wordings carefully and look for elements that can result in out of the pocket expenses. It is also advised to compare policies based on the same and make a decision only after considering every aspect.
Disclaimer: This article is issued in the general public interest and meant for general information purposes only. Readers are advised not to rely on the contents of the article as conclusive in nature and should research further or consult an expert in this regard.
