Saturday, June 6, 2009


The stories about the health insurance claims being denied by the health insurance companies are not new. The claims are generally denied because of :
1. The disease being mentioned in the excluded diseases list.
2. Misrepresentation of facts.
3. Frauds of any kind.
4. Claim not done in proper and stated manner.
5. Claim done post the specified time period
However, the insurance companies sell these health policies in order to honor claims of the rightful policyholders . There are few things that as a policyholder we can do to ensure that our health insurance claim is not denied.
1. Never mis-represent or hide any facts - First and foremost thing that we need to do is to ensure that we are disclosing every relevant information and details in good faith to the best of our abilities. Hiding any fact will work against us as generally companies will come to know about any medical fact not been disclosed by you and then they will deny the claim.
2. Inform the insurance company about your planned /unplanned hospitalisation - One must inform the insurance company withing 24 hrs of an unplanned hospitalisation and 3 days prior to the hospitalisation in case of planned one.
3. Always carry the health card with you - Health card carrying your unique number is a must for all cashless claims as it will be required by the hospital to get the cashless claim approved from the insurance company.
4. Ask for originals for reimbursement - In case of reimbursement of claims , you need to take every bill and other supporting documents from the hospital in original . These original documents will have to submitted to the hospital for reimbursement.Generally the following claim documents (originals only) are to be submitted to the insurer within 30 days from the date of discharge:
1. Duly-filled claim form along with the doctor’s certificate (forming part of claim form)
2. Discharge summary
3. Bills and receipts (including advance and final receipts)
4. Prescriptions for medicines and doctor’s advice for lab tests
5. Diagnostic Test Reports, X Ray, scan and ECG and other films
5. Be ready to pay for non-admissible charges- Some charges like telephone bills, photocopy charges etc is not paid by the health insurance company and as such must be paid by you.
6. Find out the limit for room charges under your policy cover- The hospital room rent that is paid by the insurance company is clearly defined in the policy cover and is generally a function of the total health cover . In order to avoid any surprises later, it is always best to find out the room tarriff allowed under the plan and stick to it. Else the difference in tarrif will have to be borne by you.
7. Escalate the claim request in case of denial - In case your claim is denied inspite of it being submitted with all documents and the disease being part of the policy cover , then you must escalate the matter to the higher officials in the insurance company. At times , this will work in your favour. And if it does not help you get the claim, then you might consider approaching the Ombudsman . You will have to make a written complaint to the ombudsman who will take up your matter with the insurance company.

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