The Reality of Health Insurance Understanding?
I have tried to cover and answer the top 5 health insurance frequently asked questions (FAQ) in this article. These are the common questions and queries generally asked by the people.
We come across daily with different questions and queries from friends, colleagues, and patients in regards to health insurance. They do have many questions about health insurance policy coverage.
They are not aware of the claim settlement and reimbursement process. These are the questions asked by people; listed here as health insurance frequently asked questions.
I am sorry to say but almost 60% of policyholders are confused about the policy coverage and do not know about their policy terms and conditions.
Why is there confusion?
However, these are basic questions but are very relevant when it comes to cashless hospitalization and the claim settlement process. This is the biggest irony in India is; firstly Health Insurance agents are not transparent.
They do not disclose the facts. Secondly insured/People do not read the policy document thoroughly. This is the major cause of getting into the trap unknowingly.
I have covered few basic questions here in this article those are very common but impacting customers and patients a lot.
Health Insurance Frequently Asked Questions (FAQ)
Question No. 1
If we continue to pay Health Insurance premiums for 5 years regularly without any claim; it is said that the sum insured or policy cover amount gets doubles; is this true?
Yes, this is true. You can double your sum insured if you have no claim in your health policy. No claim bonus can vary from policy to policy. Generally, a No Claim Bonus is offered up to 20% of the policy sum insured by a health insurance company. But this can vary from 5% to 20%.
No further increase in sum insured amount once you achieve 100% No Claim bonus. So you can double your sum insured in 5 years. This depends on your health insurance company’s policy terms and conditions.
Question No. 2
My father is covered with two different medical health insurance policies. One is my brother’s policy and another is mine. Can I claim from both the policies simultaneously?
Yes, you can, but not total billed amount twice from two different policies. If you are using one health insurance policy for Cashless Hospitalization and the policy sum insured gets exhausted. Then you will have to pay the balance amount from your pocket first.
The amount paid by you can be claimed from another insurance company through reimbursement. You will have to disclose the first claim’s settlement details with your second insurance company.
Once the claim is settled by the first insurance company then you can go for the reimbursement with the second one for the amount is paid by you.
OR
Let’s say the first policy sum insured is exhausted during hospitalization. In that condition, you can request your doctor to discharge the patient. After that make a new fresh admission (re-admission).
Send intimation to your 2nd insurance company for new admission. A new preauthorization request is to be sent to the insurance company. In this way, you can avail cashless benefits from both policies.
Please keep this in mind. You cannot claim the same invoice or billed amount twice from two different insurance companies. This will fall in the category of fraud and your health policy can be behold/canceled by your insurance company in that case.
Question No. 3
When we buy a Health insurance policy it is said cashless. But after hospitalization insurance refuses to re-imbrue or pay partially. How to go about this?
This is true that insurance companies in India are not that customer-friendly. But we cannot blame to Insurance Company only. There are reasons behind refusal of claim reimbursement and denial of Cashless Claims.
- Non-disclosure of facts
- The discrepancy in Past medical history in medical records
- Admission in hospital for no active line of treatment
- The Insurance Company has some queries but not answered as expected.
We should be careful while filling up the insurance proposal form. Avoid hiding any fact and do intimate insurance company if anything new ailment is diagnosed. This can be done at the time of renewal of health policy.
Be honest with the doctor and insurance company both. Do not do guesswork about your medical history while detailing your history to the doctor at the time of admission.
Please refer to your old medical records if you have any past medical history to avoid such denials. Most of the time it happens when someone else or neighbors give medical history during emergency hospitalization.
If the insurance company found any gap in history; the claim is denied. Please ensure your medical history is correctly noted in medical records.
Question No. 4
What is the common disease that is not covered in the first 2 years in health insurance policies?
Corporate health insurance policies do cover all the pre-existing ailments from Day one. There is no waiting period except maternity.
But retail and Individual health insurance policies have defined waiting periods for many diseases. Most of the pre-existing diseases are covered after a period of 4 years of continuation of individual health policies.
The First 2 years exclusions can vary from insurance company to insurance company or according to premium paid amount:
One year waiting period:
- Gastric and duodenal ulcers treatment
- Ear and Throat Diseases/Surgeries – Tonsillectomy, adenoidectomy, Mastoidectomy, Tympanoplasty
- All internal or external tumors surgeries – Cyst/Nodules/Breast Lump/Polyps surgeries
- Hernias and Hydroceles surgeries
- Anal Fissure, Fistula or Fissure surgeries
Two-year waiting period:
- Cataract surgery
- Prostate surgery
- Hysterectomy/Prolapse of the uterus
- Non-infective arthritis, Spondylitis/Spondylosis
- Genitourinary tract surgeries
- Calculus/Stone treatment/surgery
- Sinusitis
- Prolapsed intervertebral Disc (Non –accidental)
- Varicose vein treatment/Surgery
- Chronic renal failure/Dialysis
Many people do this mistake and get admitted to the hospital during the first year of the policy. They do not read the policy documents which leads to all problems. Cashless Claims are denied in view of the policy terms and conditions. People develop a misapplication against the insurance companies in that case.
Question No. 5
I have purchased a health insurance plan recently, will it cover eye and nose treatment?
If you have purchased a Health insurance policy recently then you should wait for 1-2 years for Eye and Nose treatment. Because there is a waiting period of up to 2 years in most health insurance policies to cover Ear, Nose, and Throat Diseases. Refer to the answer to question number 4 as defined above.
This depends on your health insurance company’s policy terms. The waiting period can vary from policy to policy based on the premium amount paid.
Conclusion
Kindly Read the health insurance policy document thoroughly. This will help you to avoid denial of your cashless claims. Go through your policy document, read the clauses and policy terms & conditions in detail to reduce the burden on your pocket.
I hope you got the answers you had on Health Insurance Frequently Asked Questions. But you will get the all right answers after reading your policy documents in detail.
Thank you for reading
