MUMBAI: Imagine paying Rs 15,000-20,000 every year of a health insurance policy, only to see your claim on an expensive treatment rejected by the insurance company. However, in many instances, ambiguous policy wordings, which mean different things to the company and customer, are the main culprit. Then, there could lack of understanding of medical procedures on the insurer's part. ""Some of the doctors (on the insurer's or TPA's panel) are not qualified in allopathy or do not understand super-speciality medical terms. So, they reject claimswithout really understanding the medical condition involved,"" says consumer activist Jehangir Gai.
Now that IRDA has come out with draft norms to regulate such issues, insured can hope for resolutions to many a sticky issue once they are finalised. Until then, on your part, you need to bear in mind the following points to avoid disputes with your insurer:
Take care of documentation
At the time of buying the policy as well as filing a claim, that is. Reading the policy wordings will help you understand clauses that typically cause friction. These include pre-existing diseases, waiting period, sub-limits and exclusions. Secondly, while lodging your claim, ensure you submit the diagnostic reports, discharge summary, prescription for the post-hospitalisation period, along with original bills from the hospital. The more comprehensive your documentation, the quicker will be the claim processing. Remember, however, the company can demand original bills, but not other documents like test reports. "There is no condition in the policy which requires the original reports to be handed over; only copies would suffice," says consumer activist Jehangir Gai. For reimbursement claims, the deadline for submitting the claim along with bills is 14-30 days at present, depending on the insurer and the policy.
Intimate the insurer immediately
Most insurers ask policyholders to inform them about the hospitalisation within seven days of being admitted. You may be allowed to submit the required documents later, but the company could insist on being alerted during this time-frame. If possible, do so diligently. However, if the insured is facing a medical emergency, he may not have the time to intimate the insurer. Yet, insurers tend to reject such claims citing delay in intimation. "Insured are often unaware of these deadlines, or are unable to comply with them for various reasons, which could include reasons completely beyond their control," says Rohan Dukle, director, Magus Corporate Advisors, a claim consultancy firm. If your insurer adopts this approach, you can fall back on the circular issued by IRDA last year. The note states that insurers should settle even delayed claims if they suffer from no other shortcoming. Further, if IRDA's draft guidelines are implemented in their current form, companies will be legally-bound to admit genuine claims even if there has been a delay in claim submission.
Handling claims under multiple policies
All health insurance policies contain a contribution clause, which states if you have two similar policies, the admissible claim will be split in the ratio of their sum insured. For instance, say you have two covers of Rs 2 lakh and Rs 1 lakh from company A and B respectively. Now, if your claim amount is Rs 1 lakh, company A will pay Rs 67,000, while company B will settle the balance. From the insured's perspective, the claim processing could be complicated in this case. For one, you will have to intimate both the insurers. Besides, if you are making a claim for reimbursement, both the companies could insist on original documents, causing distress to the insured. At the moment, all you can do is opt for cashless facility wherever possible. However, if the IRDA's draft circular is finalised, there will be no scope for dispute as policyholders will be able to choose the insurer they wish to claim the money from.