The most difficult part of buying health insurance is actually picking or choosing the right insurance policy. What people often forget is that the whole point of buying health insurance is that they should be able to claim it and get financial help in their time of need. And then, the claim process itself can be complicated if you don’t know what to do.  

There are a lot of aspects that need to be weighed in when choosing the right health insurance and this often leaves people utterly confused. Due to the complexity of combinations to keep in mind while comparing health insurance policies, and then during the claim process, certain myths have come into existence. It’s important to understand what is true and what is a myth to be able to make the right health insurance choice and then to ensure that you do the claim process right. 

So, to help you understand coverage and claim better, here are some insurance myths busted: 

Myth 1 – The insurance company only requires bills to reimburse the expenses

The reason most policyholders don’t get paid the full amount is that they do not attach the complete documents including the original doctor’s prescription and the reports along with the medical reimbursement claim form. Why is that so?

  • The insurance company needs to establish the need for hospitalisation. And a doctor’s prescription is evidence that the treatment and hospitalisation are requested by the doctor. 
  • There has to be an outcome of the medical services taken. Hence, submitting the reports is necessary. 

Myth 2 – Cashless treatment doesn’t require policyholders to pay at all

Often, policyholders assume that if they’re authorized for cashless treatment, they need not pay anything out of their pocket. However, it is not always true. The role of the hospital is to only send the policyholder’s documents to the TPA. Based on the terms and conditions in the policy certificate, the insurance company then establishes whether or not the insured is eligible to receive the complete claim amount. The insured is supposed to pay the deduction amount, if any, at the time of discharge. Here are a few reasons that may lead to
deductions in the cashless claim amount

  • Co-pay – Most insurance policies have a co-pay feature which implies that the policyholder must pay a fixed part of the total treatment cost as decided upon by the insurance company. 
  • Sub-limit – It is a monetary cap on the policy which means that the insurance company will not pay more than the sub-limit. 
  • Proportionate Deductions – Most insurance companies applies an upper limit on the rooms’ rent. Hence, if the patient ends up staying in a room whose rent exceeds the upper limit, the bill amount increases proportionately. And since the insurance company doesn’t pay the amount exceeding the limit as per the policy terms and conditions, the policyholder pays the deductions from their pocket. 

Myth 3 – Only the Hospitalization expenses are covered in a medical policy

In addition to the hospitalisation expenses, the insurance company also reimburses the OPD expenses i.e. out-patient department expenses. Usually, insurance companies reimburse the treatment expenses incurred during 30 days before the hospitalisation and 60 days after the hospitalisation. However, the OPD expenses must be related to the reason for hospitalisation. 

Myth 4 – Insurance pays for the treatment irrespective of the room chosen

The cost of hospitalization and other related services go up with the higher room categories. And since most of the policies apply a cap on the room rent category, the policyholder must choose the room category specified in the policy. However, if the policyholder chooses a room that exceeds the upper limit applied on the room rent, the policy will not pay for the proportionate increase in the total expenses. This is a type of condition in which the policyholder will need to pay some amount out of his pocket despite being able to make a cashless claim.

Myth 5 – Insurance offers coverage for every treatment

People buy insurance thinking that they will get coverage for the impending treatments. However, that is not the case. A claim can be denied for a lot of reasons including certain pre-defined factors that are written in the policy in the form of complex jargons. 

For example – 

  • Exclusions – It is set of certain medical conditions that the insurance doesn’t offer cover for. 
  • Waiting Period – It is a fixed duration of waiting time applied on certain diseases or medical conditions. During this period, the insured cannot claim a medical expense. 
  • PED – Pre-existing diseases and disorders are often not covered. If they are, there is a waiting period applied to them. 

This information above will help you avoid the most common policy mistakes and minimize your out-of-pocket expense.

Author's Bio: 

Anuj co-founded SureClaim to fix the broken claim experience of insurance customers. He believes technology can play a major role in empowering customers. His understanding is shaped by his decade long stint in healthcare and health-tech companies