Insurance claim denials cost hospitals $262 billion annually

Source https://www.modernhealthcare.com/article/20170627/NEWS/170629905

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What Are the Reasons for Rejection and Escalation for your Health Insurance Claims?

A family health insurance secures you and your family in an event of sudden illness or an accident. Today, medical bills and medication is expensive and increasingly becoming unaffordable. This is exactly why you need to apply for and have a health insurance policy in place.
Though one receives guaranteed health insurance claim, chances are that the same might get rejected due to some reason you were not aware of. This could have a disastrous effect on your contingency plan for the rainy days.
Here we identify the reasons for rejection of a health insurance claim:

1.Zero Knowledge of the Pre-existing illnesses

Family health insurance policies do not cover pre-existing illnesses in the initial period. The initial period ranges between three to four years. For instance, someone suffering from high blood pressure will not receive claim in the first few years. But what is a pre-existing illness?

A health condition or illness that exists before signing the insurance contract is a pre-existing illness. Hypertension, obesity, diabetes and cataract may be considered as pre-existing illnesses. It is recommended that one checks the terms and conditions of pre-existing illnesses with the said insurance company before finalizing a health insurance contract. It is mandatory that you declare a pre-existing health condition or illness.

2.The Terms and Conditions of the Policy

Make it a point to read the health insurance policy, word by word as the legal language of the policy can be complex to understand. The applicant should read through the health insurance form to know the exclusions, understand the coverage limits, and other terms and conditions.

3.Lack of Correct Information

Another major reason for rejection of claim by the health insurance company is the provision of incorrect information by the insurance holder. Many a times it so happens that the application form is filled by an insurance agent. Now an insurance agent may not have detailed knowledge of your medical history due to which the health insurance company in question rejects the claim. To receive a timely claim, ensure that you have provided correct details in terms of the name of the patient and the doctor, correct set of papers, hospital bills and other relevant information. Therefore, be meticulous about filling the health insurance form as this will benefit you in the long run.

4.Room Rent Sub-limit

Room rent also is one of the factors taken into consideration for the health insurance claim. The cap on reimbursement of the claim is set as per the room-rent limit. Usually it is recommended to select a hospital room with rent equal to one percent of the insured sum. For example, if the sum insured is Rs. 2, 00,000 then the room rent should be Rs. 2,000 in a worst-case scenario.

5.The Insured forgets to renew the health insurance

Always remember to renew your health insurance policy before the due date. If you forget to renew the policy, the claims filed during the waiting period i.e. the start date and the end date won’t be taken into consideration. The Insurance companies generally sends the renewal reminders in advance. But it will be wise on your part to keep in mind the due date and renew the policy.
The insured customers file escalations against the health insurance company when the latter rejects payment of claims due to any one of the above reasons. To avoid such tricky situations, it is strongly recommended that the insured should have thorough knowledge about the health insurance policy and the insurance company in question.

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Challenges Involved in Cashless Mediclaim Insurance

1. The Document Jumble in during treatment

Availing cashless treatment requires adherence to documentation, especially the pre-authorization form which is to be submitted to the TPA to facilitate cashless treatment. Policyholders, being ignorant, fail to stick to the documentation, which results in difficulties in getting a cashless claim. And for this reason, hospital face many difficultly, Insurance Co. /TPA deducted the amount from Claims and hospitals has bear this amount

2. Getting a Part of the Claim Settled due to not understanding policy wording X

A very common scenario is where the Mediclaim insurer settles only a part of the total expenses incurred. For instance, you might be hospitalized for appendicitis for which the insurer is paying about Rs.25, 000. However, you develop a complication post-surgery which results in an extended hospital stay chalking up a total bill of Rs.40, 000, out of which the Mediclaim insurer pays only Rs.25, 000 as cashless claim and the pending amount is later reimbursed.

3. Not Getting the Facility of Cashless Treatment due to lack of Experience

This happens mostly in emergency cases where the TPAs require time to facilitate cashless Mediclaim treatment. In such cases, the insured or his family is asked to bear the costs and later get them reimbursed from the insurer despite the insured being admitted in a network hospital Leave all worries and just take care Patients treatment, we will help you