Things to keep in mind for a smooth settlement of health claims

The claims experience is the single biggest moment of truth for policyholders. That is why insurers are constantly striving to improve it. Previously, customers used to compare policies on the basis of the premium amount, but now they consider an insurer's claims process to be one of the key deciding factors. Policyholders will have better experience if they are mindful of the points mentioned below before filing claims.

Look for claims related sub-limits:

One should buy health insurance policies without sub-limits. Sub-limits cap the amount that can be claimed for specific hospitalisation or medical treatments even if the sum insured is big. Fill the proposal form yourself: Customers should take interest in filling the proposal form and not depend on third parties and intermediaries in doing the same. The latter can lead to serious mistakes in declarations. Transparency at the proposal stage makes claims hassle-free.

Disclose all material facts:

While buying a health insurance policy, a customer should declare all material facts in the proposal form. Any discrepancy at a later stage may lead to rejection/discussion of the claim. Therefore, correct information related to tobacco/liquor consumption, occupation, income, diseases, etc, must be shared.

Share complete and accurate information:

Incomplete or inaccurate information about any major previous hospitalisation or any existing condition may lead to claim rejection. Hence, one must share all the relevant information at the time of filling the proposal form. It may increase the premium amount a little, but will prove to be very beneficial in the long run. Also, it is advisable to go for medical tests at the proposal stage, even if your insurer does not insist on it.

Read your policy documents:

Customers are advised to go through the policy documents and be aware of terms and conditions of their policy. When in doubt, they must seek clarifications from their advisor, insurance agent or the insurance company at the time of buying the policy.

Know your exclusions:

The policyholders should check with the insurance company or the intermediaries the complete list of exclusions before filing a claim. Some normal exclusions that one should keep in mind are:

>> Self-inflicted injury, suicide or attempted suicide or abuse of intoxicants
or hallucinogens including drugs and alcohol
>> Participation or involvement in naval, military or air force operations,
racing, diving, aviation, rock or mountain climbing, any breach of law with
criminal intent
>> War or any act of war, act of foreign enemy, public defence, rebellion,
revolution, insurrection, military or usurped acts, chemical, radioactive or
nuclear contamination
>> HIV/AIDS, sexually transmitted diseases
>> Pre-existing conditions and their complications
>> Any psychiatric or mental disorder-related ailment

Choose cashless service:

For a seamless claims experience, policyholders should avail of the cashless benefit as in this the insurance company directly settles bills with the hospital. It is better than the reimbursement policy, which requires the policyholder to pay upfront and get reimbursed later.

Don't delay filing claims:

In order to avoid hassles during the claims procedure, the policyholder must intimate the insurer or the TPA as soon as possible. To avail of cashless claims in case of planned hospitalisation, the policyholder must inform the insurance company and fill up the cashless authorisation form at a preferred network hospital at least seven days prior to the hospitalisation date. In the case of an emergency, he must inform the insurance company at the time of admission. For reimbursement claims, he must inform no later than 30 days of the discharge date.

Keep all documents in order:

It is vital to establish proof of the medical treatment that was sought during the illness/hospitalisation.These include copies of all important documents like receipts, bills, discharge summary, investigation reports, consultation sheets, etc, as the originals must be submitted while applying for a reimbursement claim. In case of cashless claims, it is advisable to keep copies of important medical documents like receipts, bills, discharge summary, investigation reports, consultation sheets, etc, as they comes handy in case the documents are misplaced or lost at either end.

Gather all medical proof:

In some circumstances, a claim may be rejected on the basis that the treatment was medically unnecessary. To substantiate that the treatment was necessary and valid if the ailment is covered, the policyholder must gather medical opinions and medical research that will help him/her prove that the treatment was necessary.

Renew your policy regularly:

As every health insurance policy comes with some waiting period to be able to claim for certain pre-disclosed ailments, it is imperative that all customers renew their policy regularly to avail of its full benefits.

(The author is CEO, Apollo Munich Health Insurance)