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7 reasons why your insurer is making you bear hefty medical bills – ​Why claims may have high deductions

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7 reasons why your insurer is making you bear hefty medical bills - ​Why claims may have high deductions

7 reasons why your insurer is making you bear hefty medical bills – ​Why claims may have high deductions | The Economic Times

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​Why claims may have high deductions

(Based on text by Sanket Dhanorkar)With the rise in Covid-related health issues, many policyholders are finding that health insurance claims are not being settled fully. Non-covid claims are also piling up. Hospitalisation costs, especially for Covid patients, have been alarmingly high. Given below are the reasons why your insurer is not paying you or you are bearing a large portion of the medical bill.

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​Massive room rents
Some hospitals are charging a steep premium for rooms for covid patients, owing to high costs of maintaining isolation wards, sanitization etc. If you opt for a room charging more than allowed in your policy, you are bound to see huge deductions in your claim settlement amount. Proportionate deduction applies on all associated medical expenses, it is like a trickle-down and the policyholder has to bear the balance expenses out of his own pocket.

At time of hospitalisation, you should ascertain if room rents are linked to other expenses. Stick to a room with rent up to permissible sub-limit. Opt for a policy without room-rent sub-limit or buy as an add-on cover. However, this comes at higher premium.

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Exorbitant charges
Some hospitals may charge more for other expenses which are not a part of your health plan. Thus, insurers may only settle claims based on predefined rates, as recommended by the General Insurance Council. This too can result in significant cuts in the claim amount.

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Minimum 24 hours hospitalisation

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Minimum 24 hours hospitalisation

In most health policies, a minimum 24 hours of hospitalisation is required for a claim to be accepted. This is excluding a few daycare procedures, which are explicitly mentioned in your policy documents. If a Covid patient chooses to be treated at home instead of getting hospitalised, he will likely not get reimbursed, unless specifically covered in policy.

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​Waiting periods
Newly issued policies typically carry a waiting period of up to 2-4 years for any pre-existing diseases. During such period, any related claims will be denied. Some policies have distinct waiting periods for treatments towards specific illnesses, these are separate from the initial waiting period. This is apart from standard initial waiting period of up to 30 days during which no claims are admitted. Covid-dedicated plans also come with 15-30 day initial waiting period.

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​Co-payments
Co-payments mean that you pay part of the claim in some medical situations while the insurer takes care of the rest. Say you have opted for 20% co-pay, then your insurance provider will bear 80% of the claim amount while the rest will be borne by you. Normally, co-payment is higher for policyholders in higher age groups. If you opt for a lower co-payment amount, you will have to pay higher premiums.

It is better to opt for a plan without co-pay clause. If you do go for a plan with co-pay options, make sure you have adequate finances to cover your share of medical bills.

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​Sub-limits
Apart from room rent limits, your policy may cap how much is payable for a particular illness. Even if your sum insured is high, you may not get 100% coverage and may not be able to claim entire cost of treatment owing to sub-limit on specific medical procedures. Sub-limits are used for procedures such as cataract, total knee cap replacement, kidney dialysis etc. So go through the sub-limit clauses carefully.

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​Policy exclusions
Health plans categorically exclude certain expense heads from coverage. Most don’t cover maternity or participation in adventure sports or activities, abuse of intoxicants like alcohol etc. Many general expenses during hospitalisation are not claimable like registration and discharge charges, ambulance charges, toiletries, etc. For Covid, if you quarantine at a non-recognised centre for treatment, medical expenses may not get covered. Also, getting hospitalised without recommendation of a qualified doctor will not be permitted as admissible claim.

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