The do’s and don’ts of making a health insurance claim

Make sure you call and inform the insurer of your health-related emergency and which hospital you are going to be admitted in.

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Make sure you call and inform the insurer of your health-related emergency and which hospital you are going to be admitted in.

A health insurance policy covers medical uncertainties and ensures quality medical treatment at the time of need. However, it can be agonizing if the insurance claim filed gets rejected by the company. In order to ensure a hassle-free claim settlement process, here are some do’s and don’ts you should follow while filing a health insurance claim.

The Do’s

Inform your insurer: Make sure you call and inform the insurer of your health-related emergency and which hospital you are going to be admitted in. Check if the hospital of your choice is part of the network list of hospitals where the insurer provides the cashless facility. If you are going in for a planned procedure, inform them at least a week ahead of the due hospitalization or treatment.

Read your policy: Make sure you read the terms and conditions of your policy so that you know exactly what is covered under it. The ‘Exclusions’ section in the document will guide you on what is not covered under the policy. In addition, keep your policy copy in a safe and accessible place to you and your family, as you will need it to make a claim. Besides, there is a list of non-payable items as per the policy, which may be referred to in order to understand and get an idea on the inadmissible components in a claim.

Pay attention to the waiting period: ‘Waiting period’ is the period during which you cannot make a claim. There are different categories of waiting period – ‘initial waiting period’, ‘pre-existing disease waiting period’ and ‘disease-specific waiting period’.

Check co-payment amount: You may be liable to bear a certain portion of the expenses; you can make a claim only if the expenses exceed this amount.

Share all your health details: Be forthright and truthful with your doctors and your insurer about pre-existing conditions, prescription or non-prescription drugs and your symptoms.

Save your documents: In case you do not avail cashless treatment, you should save all your hospital bills, reports, pharmacy invoices, results of diagnostic tests, etc. Make sure you submit all the requisite documents to the insurance company in original to make your claim. Double check all the information (your name, age, policy number, etc.) that you have filled in the claim application form to ensure accuracy. Also, ensure all the documents are signed and stamped by the doctor and save all the original receipts and reports of pre and post hospitalization, which are to be submitted to the insurer on filing a claim.

Use the insurer’s mobile app: You can intimate your insurer or inquire about the claim process through the insurer’s mobile app. This is a convenient way to initiate your claim process. You can also use the mobile app to show your health insurance card, which is available once you register on the app.

The Don’ts

On the other side, there are some things that you should never do when you make a health insurance claim:

Suppress information: Being less than truthful about any health condition or drug or any other material related fact could lead to denial of your claim.

Delay in filing claims: Ensure there is no delay in filing your claim with the insurer.

Do not claim for hospitalization under 24 hours: Health insurance does not cover any hospitalization under 24 hours unless it’s a day-care procedure (Please refer to your policy document to know more about the day-care procedures listed and covered under your policy). You should not file a claim for such an incident. Further, if your treatment does not warrant hospitalization, i.e., you can be treated on an outpatient basis, do not seek hospitalization.

Excluded conditions: If you are suffering from infertility or sterility or have a pre-existing condition or a congenital disease or have to undergo only diagnostic tests and not treatment/hospitalization, you will not be able to make a claim. Pre-existing condition implies ailments that you already have at the time of purchasing the policy. You must declare your pre-existing ailment at the time of applying for your health cover. Claims related to alcohol-related hospitalization and treatments are also inadmissible.

Expired policy: Your insurer will not entertain any claims if your policy has expired.

A health insurance policy comes handy during a medical emergency. Keeping in mind the rising medical costs, it is important that you plan ahead, follow the rules and make the most of your health insurance policy.

By Diwaker Asthana, Executive Vice President, Accident & Health, HDFC ERGO General Insurance

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