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5 Common disputes in the health insurance claim process during COVID
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What are the unexpected claim disputes in health insurance during COVID

Health insurance claims are a cardinal part of your health insurance plans. The health insurance claim process is a tiresome one because it demands unfathomable paperwork. Sometimes, your claim might get denied or rejected due to process inefficiencies. The health insurance claim process is synonymous with worry or anxiety because, on the one hand, you need to deal with your or your family member’s health condition. On the other hand, you are anxious about whether your claim will be approved or not by the insurer. If it is approved, what portion will be paid off by the insurer, and what amount will be deducted?

These are some disputes that make your health insurance claim process more exasperating. All these dispute scenarios may add enough agony and pain to a situation. You should be aware of these situations in advance. Go through EOB in medical billing of your policy and check what it covers for your healthcare expenditures.

5 Common disputes in the health insurance claim process during COVID

Let’s take a look at 5 common disputes in the health insurance claim process and how to deal with them.

  1. Room rent limits and proportionate deductions
  2. Medically Necessary Hospitalizations
  3. Active Line of Treatment
  4. Reasonable & Customary Clause
  5. Lazy errors in the proposal form


Room rent limits and proportionate deductions

Despite having sufficient sum insured, policyholders were often astonished that insurers paid off only certain parts of their claims. Most health insurance plans have a limit on the room-rent amount. They usually offer 1-2 percent of your total sum insured per day as room rent. If you choose a costly room beyond its limit, you need to pay a humongous amount from your pocket.

Total Sum Approved = Total Sum Claimed X (Room-rent Approved / Room-rent Claimed)

For example, if your room-rent restriction is Rs 5000 per day, and you choose a room that costs Rs 10,000 per day, then, Your Sum Approved = Sum Claimed (5000/10000) = 0.5 X Sum Claimed.

If you want to escape from this scenario, you should know your room-rent limits. Handpick a room that falls within this category. If your limits are insufficient and you select a costly room, then you need to pay a part of your bill from your pocket.

Medically Necessary Hospitalizations

Health insurance plans compensate for only your hospital expenditures that are ‘clinically necessary.’ As per this definition,

  • The insured policyholder should get admitted to a hospital or healthcare facility for medical management
  • The treatment plan should come up with care, intensity, and duration
  • The treatment should be recommended by a professional medical practitioner/ doctor (who is not related to the patient)
  • The person should be treated only in India
  • If you cannot fulfill all these conditions, then the insurer will decline your claim because the hospitalization was not clinically required.

Before your admission, ensure that your treating doctor must recommend hospitalization in writing.

Active Line of Treatment

An insured policyholder will only get an insurance cover if he/she opts for an ‘active line of treatment’ at the time of hospitalization. This means a patient might not get any insurance cover if he/she is admitted to a healthcare facility for observation, diagnostic tests, or monitoring.   

This is very much applicable in this pandemic situation. Now, many people often get admitted to hospitals once they find COVID-19 positives in the tests. And to quarantine, they often get admitted to hospitals. If they didn’t receive any treatment, then such claims won’t be reimbursed by insurers.

So, know why you are getting admitted before seeking admission. For example, suppose you are getting admitted to a hospital to monitor your condition (suppose chest pain or breathlessness) and come back home without any treatment. In that case, you need to resolve medical bills and hospital expenses from your pocket.

Reasonable & Customary Clause

These days, medical inflation is thriving hurriedly, and hospitals are also charging like anything—a health insurance cover safeguards insurers against these exorbitant and stroppy charges. Before paying you, insurers evaluate all the charges by analyzing the costs imposed by similar hospitals in the same area. After their assessment, they only pay what they find to be reasonable. So now, you need to pay the remaining amount from your pocket.

Though you can’t control the costs levied by the hospital, still, you can closely monitor the bills. So, verify every bill before paying out of your pocket. Take estimation of the hospitalization costs in advance and compare the costs of various hospitals. If you think your hospital is charging exorbitant, you can pay the bill out of pocket or shift to another hospital where charges are budget-friendly.

Lazy errors in the proposal form

An insurance company grants your insurance policy based on your details and healthcare declarations submitted by you. In the case of misleading information, the insurer has every right to deny your claim. In addition, they can cancel your policy altogether in the context of misrepresentation.

Always provide correct and exact detail of your health condition to the insurer. Mention all pivotal and minor health issues that you are suffering from. Also, include any injury or surgery that you have undergone. Every minute detail is imperative when it comes to health declarations.

Sometimes, you may put an improper pin-code when filling up the proposal form online. Or there is a discrepancy in your personal information like birth date or full name; this info does not match the hospital documents. This may also cause claim rejection. So, fill up your form carefully without any hurry.

These are some claim disputes in your health insurance plan.

If you can’t pay off your hospital bill or only pay a part of your bill, then a portion of the bill could have been sent to collections as per hospital bill collection laws. Talk to your insurance provider or hospital if you can’t pay off your due amount. Your insurer will set up a payment play but ensure that they give it in writing. 

You can even approach an arbitrator who will settle an insurance dispute between your insurance company and you. The arbitrator assesses the facts and offers a solution on how to resolve the dispute. If you are losing insurance arbitration, you may approach the court, and the court will take the final call regarding your dispute.

So before initiating a claim, know what your policy covers and whatnot. Don’t conceal anything and provide proper information to your insurer to minimize discrepancies regarding insurance claims.

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