Reduce chances of claim denial

Know the exclusions, make full disclosures and go to a consumer court in case of a dispute

In April 2015, Kiran Gadia, a 44-yearold entrepreneur from Godda, Jharkhand, underwent surgery for removal of gallstones. While the insurer reimbursed her for the operation (around ~55,000), it did not compensate her for the tests, an amount of ~10,500. Neither the insurer nor the third-party administrator explained why this amount was not being reimbursed.

In another case, 65-year-old Ajay Ranjan Mukherjee was admitted to a hospital for a suspected infarction. At the end of a week-long stay, nothing wrong was found. He was handed a bill of around ~55,000. The insurer denied his claim. The reason: a junior doctor had noted in his case history that he had a pre-existing blood sugar condition. “In all previous and later tests, he was never found to have this issue,” says his son, Partha, who pursued the case for a while but then gave up as he had moved to another city.

Denial of mediclaim is a frustrating experience. To improve your chances of securing the claim, it is important to take certain steps. Know what’s not covered All potential buyers should read the policy document and get to know how it works. 90-day cooling period: Many policies come with an initial cooling period of 30 to 90 days during which no ailment is covered. Only a claim for an accident is accepted. Exclusions: A list of conditions called exclusions will not be covered by your policy for two years. These include procedures like removal of tonsils, gall bladder stone, etc. Conditions that don’t require immediate treatment are included here to prevent misuse. Pre-existing diseases: If a person declares that he suffers from certain pre-existing diseases (PEDs), or these are revealed in the medical check-up, those conditions and problems related to them will not be covered for a specified waiting period. “A mediclaim covers the ailments that you contract after buying it, not those you already have,” says Puneet Sahni, head - product development, SBI General Insurance. The waiting period for PEDs can vary from two to four years. “Once the waiting period gets over, pre-existing diseases will be fully covered,” assures S Prakash, senior executive director, Star Health Insurance. Sub-limits: Some insurers might offer their policy at a lower premium, but these could have sub-limits. Reimbursement for certain charges like room rent and ICU are capped, say, at one-two per cent of sum assured. Policies also come with disease-specific sub-limits.

Remember that all hospital expenses are linked to the category of room you rent. Suppose you have a policy where the cap on room rent is one per cent of the sum assured. Your sum assured is ~5 lakh and, hence, the room rent sub-limit comes to ~5,000. When you get admitted, the hospital might charge you ~50,000 for a procedure if you opt for a twin-sharing room. But, if you opt for a single room with a rent of ~7,000, the same procedure may cost ~75,000. In that case, you will have to pay the balance ~25,000 out of your own pocket. Avoid policies with the room rent sublimit, or have a high sum assured. Co-payment clause: Senior citizens’ policies come with this clause. When a bill arises, you have to bear a specific percentage of it first, after which the insurer will pay the balance. If a policy is purchased in a smaller town and you avail of treatment in a metro, the insurer may reimburse only a part of the cost. Expensive items: At the time of buying the policy, clarify with the insurer if expensive items like stents (imported ones can cost above ~1 lakh apiece) will be covered. While the more expensive policies offered by private health insurers might cover these items, others might not. “If it is medically indicated, it will be covered,” says Prakash. What can you do? Buy early: The earlier you buy, the better. “At an early stage, you are likely to be disease-free and will not have to face a waiting period,” says Arvind Laddha, chief executive officer, Vantage Insurance Brokers. Make complete declaration: The mediclaim proposal form asks pointed questions: Do you have PEDs? Do you have a family history of diseases? Answer all these questions honestly. Many people think they can get away by not declaring PEDs. When they go to a doctor, patients make full disclosure of their medical history to get the best possible treatment. Insurers have access to a hospital’s records. “If it is revealed in the medical history that you had a pre-existing disease which you did not disclose, your claim will be rejected,” says Sahni. Suggests Laddha: “Keep a copy of the proposal form to be used as a reference in case of a dispute.” Don’t skip medical check-up: Generally insurers don’t ask for a medical check-up till 45. If you have a pre-existing condition, a check-up becomes essential. If you skip the check-up and it is revealed that you had a condition, your claim will get rejected. Legal recourse In case of disputes, if the insurer doesn’t pay heed to your letters or e-mails, contact a lawyer and send a legal notice. “Trying to negotiate with the insurer and lowering your claim would be a mistake,” says Shivendra Singh, advocate, High Court of Delhi. He advises approaching the consumer courts for speedier redressal and to get compensation.