March 2014 ~ Vardhman Insure Finvest Blog Powered By Wealth Smart Planners

All you need to know about exclusions in your Health Insurance Policy? Claim rejection is the most disappointing subject in a policy holder's life. The customer starts loosing trust in the company and feels betrayed. They feel the company gives unrealistic reasons for rejecting their claims. An insurance claim rejection results in a huge loss to customer, financially, because now they have to pay the medical expenses...

All you need to know about exclusions in your Health Insurance Policy?

Claim rejection is the most disappointing subject in a policy holder's life. The customer starts loosing trust in the company and feels betrayed. They feel the company gives unrealistic reasons for rejecting their claims.

An insurance claim rejection results in a huge loss to customer, financially, because now they have to pay the medical expenses from their wallet. This usually happens to people who have less or no idea about what is included and excluded in their policy. To know the inclusions and exclusions, a policyholder should read the terms and conditions carefully.

Let's understand what does a health insurance policy does not cover.

What are these exclusions?

In almost all cases, where claims are rejected, the main reason is lack of knowledge about the insurance policy. The claims are usually refused depending upon the points mentioned in the policy documents.

Most of the time, policyholders don't bother to read the terms and condition that explain in detail the inclusions and exclusions. There are various clauses like waiting period or exclusion of pre-existing illness, which customers do not fully understand and in some cases do not bother to know. They simply view a health insurance policy as a product that will pay their medical bills and other related expenses. This mindset lands them in a huge financial mess during the time of medical emergencies.

The below article is drafted to enlighten you about the 4 important exclusions that almost every health insurance company has. Read below to know the details about these exceptions.

1. Pre-existing Illness

Nearly every company has this exclusion. Under this rule, most of the companies do not cover diseases that are already detected in the patient. Generally, pre-existing diseases are not covered for the initial few years (the exact years differ from company to company). For instance, if someone is suffering from kidney stone, then any medical expenses occurred due to kidney stone will not be covered for first few years.

This is the reason why it is said that one should buy health insurance as soon as possible, so that the initial few years are passed then you'll be covered for a range of diseases.

2. First 30-90 days waiting period

Nearly every health insurance companies do not give cover for any treatment happened in 30-90 days of the policy taken, except medical expenses caused due to accident.

3. Permanent Exceptions

Permanent exclusions mean a list of illnesses that are never covered in health insurance policy for whole life. They are excluded from the coverage list of nearly every health insurance company in India.

Policyholders can get this list of permanent exclusions in the policy document that has a category with the name ‘Permanent Exclusions.' Before buying a policy you are expected to read this list. Although nearly every company has the same list of exceptions, you must read it anyway. You can get this list on the company's website.

Some of the common ‘Permanent Exclusions' includes:

* AIDS and diseases related to HIV

* Dental treatment

* Circumcision or sex change operation

* Birth control procedures, hormone replacement therapy, infertility etc.

* Routine medical care, eye and ear examinations and cost of spectacles.

4. Waiting Period Concept for Chosen Diseases

No matter from which company you buy a health insurance policy, each of this policy has a ‘Waiting Period' concept for a list of selected diseases. The chosen illnesses will not be covered for first few years, which is generally 2-4 years. For instance, if you buy a policy in 2014, the selected diseases will be covered in 2016 or 2018.

This is the most important point, which customers do not pay attention to. If they get hospitalized for the illness under the waiting period in the first year, the claim gets rejected. In this case, the policyholder blames the company for bluffing.

* Some of the common illnesses which are part of the waiting period list are:

* Dilation and Curettage

* ENT Disorders & surgeries, Deviation and Sinusitis

* Kidney Stone, Gall Bladder Stone

* Arthritis, Spinal Disorders, Joint Replacement Surgery and Osteoporosis.

* Cataract

* Internal Tumors, Skin Tumors, Cysts.

The Bottom Line

Health insurance policy should be taken to make sure that you are covered from future problems. But most people buy insurance policy when a disease strikes them, and that's when a health insurance policy won't help you much. One should buy a policy when they are healthy and fit; to make sure they get covered for any long term medical issues.

Cashless Health Plan: How to make the best use of it

The Cashless Health plan is one of the best advantages in a Health Plan. Most of us assume that having a Cashless Health plan means that we will be covered in case we are admitted in a hospital. It's an easy assumption to make, but there is much more to a cashless health plan. You should be aware of the many details in the fine print like the ones below.

Day Care Procedures

Let us say you visit a hospital, undergo a minor surgery like Lithotripsy (Kidney Stone Removal) but do not need to stay at the hospital. Do you pay in cash for such a surgery? Or can you use your Cashless Health Plan? Yes you can avail this facility. You need to file such a claim in the same manner as you would any other claim. Most companies today mention a list of procedures that are covered in the cashless facility even though it does not require hospitalization. This is because scientific advancements have made many procedures simpler today. Other than Lithotripsy, the list may contain procedures such as Haemodialysis, Radiotherapy, Chemotherapy, Dental Surgery, Eye surgery, Tonsillectomy and a host of others. For example LIC Jeevan Arogya considers 140 day care procedures. But plan ahead of the surgery, inform the TPA (Third party administrator) and get their approval for the procedure.

Network Hospitals

Know your list of network hospitals. Your cashless policy can only be used if you are treated in one of the hospitals approved by the TPA. When buying the policy you should have been given this list. At most of the network hospitals, there will be a TPA desk, which helps you with all the forms and procedures that are needed for a cashless claim. The insurance company will then settle all the bill with the hospital and you need not pay for your expenses. If treatment is taken outside a network hospital then you will have to pay for all the expenses and later get it reimbursed from your insurer. However note that most insurers do not pay the whole amount if treated outside their network hospital.

Day Limit

All plans have a maximum number of days in hospital covered under the cashless plan and also the maximum amount for rooms per day. Some even differentiate between ICU stay and Non ICU stay. Some have a different cap per year and also a lifetime cap. Hence if you know your procedure will take place after a few days, consult with your doctor and check whether you can get admitted later.
Documents required

This is the most important and often overlooked part of the cashless procedure. Firstly make sure you have the TPA approval. Have all the diagnosis results, and the doctor's advice summary. Check that the bills do not have any items as miscellaneous or sundry or others. Make sure the hospital gives a complete break-down of every expense in the total amount. Finally have the discharge summary and fitness certificate ready as without this you cannot even start your cashless claim.

Conclusion

If you hold a Cashless Health Plan, read the terms carefully. Do not delay in filling up the necessary forms and get the TPA approval as early as possible if you do not wish to unnecessarily pay from your own pocket.

All you need to know about exclusions in your Health Insurance Policy?

Cashless Health Plan: How to make the best use of it

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