What Is Health Insurance?
A contract for health insurance is made between an individual or his or her sponsor (an employer or a community organization) and an insurance provider (such as the Government or an insurance firm). Individual insurance contracts can be renewed annually, monthly, or for the rest of one's life.
Getting insurance helps you control your risk. Purchasing insurance gives you protection against unexpected financial losses. If something unfortunate happens to you, the insurance company covers you or a designated beneficiary. If an accident happens and you don't have insurance, you can be liable for all associated expenses.
Types Of Health Insurance
Health Insurance Policies can be divided into two categories: Family floater policies and Individual or self-plan policies. An individual policy would only cover and benefit the primary policyholder, as the name suggests. On the other hand, a family floater plan only offers coverage for one plan that covers every family member, including your spouse, dependent children, parents, parents-in-law, and dependent siblings.
- Policy for Individual or Personal Health Insurance: An individual health insurance policy is issued in the name of a single policyholder, meaning that the benefits and total insured coverage are meant only to the insured and do not extend to others. Here, the policy is purchased by the individual to protect their own health, which in turn offers financial support in the event of an emergency relating to their own health.
- Plan for Family Floater Health Insurance: An individual and his family members can both receive sum insured coverage under a family floater health insurance policy. The family health insurance plan is the better option because it serves as a cover for all members of the family as compared to purchasing individual policies for each member.
Reasons for Claim Rejection
- Deductions For Fair Use
- A proportionate use happens when you select a hospital room whose rent is above your eligibility. In this case, you could lose a significant amount of money because all other expenses from the room rent also qualify for the deduction in the same amount.
- For instance, if you were qualified for a room at Rs 5,000 per day but decide to pay Rs 10,000 instead, the appropriate reduction will be made from your total bill, not just the room rent portion. Therefore, you will only receive 50% of the whole amount, or 5 lacs in claims, if it is for 10 lacs.
- There are still many old PSU policies, including a room rent limit. Checking this before choosing the hospital room is always suggested as even corporate insurance has a certain amount limit.
- Information About Previous Medical Conditions and Unhealthy Behaviors
- Health insurance claims may be denied if information regarding one's own pre-existing illnesses, family medical history, sedentary lifestyle, and habits such as alcohol consumption and smoking are ignored. To avoid paying a higher premium or having their coverage rejected, some consumers could choose to hide this information.
- You have to include information about any pre-existing conditions you may have on the health insurance application form. You should include any family history of an illness in the medical history or family history section.
- If you smoke, the insurance provider might inquire about your daily cigarette consumption. If you drink alcohol, you can be asked to declare how much and how often you drink it.
- During The Waiting Period, Filing A Claim
There might be waiting periods connected with every health insurance plan. A claim will be rejected if it is claimed within this waiting period. Between these waiting times are the following:
- A Thirty-Day Hold: There is a 30-day waiting period after the issuance of a new policy, during which no claims may be submitted. This does not apply to any claims caused by accidents.
- The Age Of Pregnancy: In general, maternity coverage under an insurance policy becomes effective following a 24- to 36-month waiting period. Furthermore, coverage might only cover two deliveries.
- Waiting Periods For Certain Illnesses or Treatments: After a 24-month waiting period after the policy's launch, claims for the treatment of specific diseases or procedures can be submitted. The insurance policy paper contains a detailed list of these conditions and processes.
- Pre-existing disease waiting period: After waiting 24 to 48 months from the date of coverage start, the claim for treatment for pre-existing conditions can be used.
- At a Non-Network Hospital, Submitting A Cashless Claim:
- A cashless claim will only be accepted if it is submitted at a hospital that is listed in the hospital network of the insurance provider. Consequently, before being hospitalized, find out from the hospital if it has registered with the insurance company as a network hospital to submit a cashless claim.
- For treatment received at a non-network hospital, you will be responsible for covering the costs of hospitalization with your own money. You can get in touch with the health insurance company and file a payment request.
- Policy Lapse: There have also been cases where people have been waiting a week or a month to renew their insurance policies, and when they do, they get sick and their claim is rejected. The reason for this is because the policy ends on the last day. Therefore, insurance will not be accepted even if a person is admitted to the hospital only a few hours later. It's essential to renew the policy every year before the deadline due to this reason.
- Maintain Records: Keep track of all of your prescriptions, invoices, and Medical Bills in addition to any supporting documentation for your claim. This will protect against inconsistencies and speed up the procedure.
- Discuss With Your Medical Experts: Use means of communication open regarding your insurance coverage with your healthcare provider. To reduce the chance of a claim rejection, go over treatment alternatives and costs with your insurance provider to make sure they comply.
- Check The Claim Before Sending It: Go over all the details provided in your claim carefully before sending it in. Verify for any mistakes, errors, or discrepancies that can result in a rejection.
Conclusion
In conclusion, Rejecting Insurance Claims is common, but there's no reason to panic. Make the required adjustments before re-submitting your claim after taking the time to understand why it was rejected and what to do in case your health insurance rejects a claim.
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- Why Your Health Insurance Claim is Eliminated
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- Top Reasons For Health Insurance Claim Rejections
- Top Reasons For Health Insurance Claim Rejections: A Simple Definition