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Why are health insurance claims delayed? Here are the five reasons

In case, you are undergoing any long-term treatment or any accident, then the Health Insurance Plan ensures that your family will not face financial problems. It covers your medical and hospitalization expenses up to a certain limit insured by the policy. In the COVID19 period (period of crisis), people realized the importance of the health insurance plan. After enrolling in a health insurance plan, it becomes the responsibility of the insurer to cover the financial needs of you and your family.

Health insurance claims play a very crucial role in choosing appropriate health insurance plans. A Health Insurance claim is a request made by you for direct payment or reimbursement for medical and hospitalization expenses. You can access this benefit after submitting a claim to your insurer. To submit an insurance claim, you have to follow some procedures and documents and require information to file it. 

But if you want to ensure an easy claim settlement process, you must check the document. Some common hindrances might delay the claim settlement process. So let’s have a look at some causes, due to which health insurance claim could be delayed.

Reasons for delay in a health insurance claim:-

  1. Not following the right procedure:- As a policyholder, you should choose medical health insurance for the coverage of your medical expenses. For any pre-planned medical expenses, you should apply for cashless treatment. The cashless claim process reduces the burden of any monetary tension from your head. So, you need to follow some steps for this process: 
  • Obtaining the pre-authorization form either from the hospital desk or your health insurance company.
  • Fill in accurate details of patient ( insurance holder) and policy.
  • Associated doctor need to fill in details regarding hospitalization expenses and the estimated cost of the procedure.
  • The pre-authorization form has to be sent to the health insurance company with required and duly attested documents.
  • Then the Insurance provider will review your form and documents. After successful completion of this process, the insurer pre-authorizes your claim.

Here, pre-authorization is not a guarantee that your insurance provider will settle your hospital bills. Pre-authorization means that your insurance provider has sanctioned a specified amount in respect to the final invoice from the hospital. In case, the insurer gets any error in this process, then it causes a delay in the claim settlement process. 

In emergency cases or unplanned hospitalization procedures, the hospital asks you to deposit a certain sum of money. In this case, you didn’t have enough time to go through the whole pre-authorization procedure. So, this sum of money will reimburse you later

  1. Not filing the claim at the appropriate time: – It is the most important reason for the delay in the claim settlement process. Every policy has its stated deadline within which you must file the claim after the medical procedure is done. This deadline varies from insurer to insurer, but it is usually a period of 7 to 14 working days. So, as a policyholder, you have to file a claim within this period. In case, you ignore this deadline then you can expect a delay in the claim settlement process.
  1. Exchange of information between Hospital and Insurance provider: – The pre-authorization process is a simple and specified procedure. But the claim process can be delayed due to some settlement issues between the hospital and the health insurance company. 

In many cases, the hospital delays sending the patient’s discharge summary to the insurance company. Also, the Hospital may delay sending final bills to the company. If the hospital provides details of bills to the insurance company without any delay, then the claim settlement process becomes relatively faster.

  1. Not keeping your health insurance paper in one place: – Paperwork of the health insurance plan is the most important aspect and you should keep it safe and secure. You should always keep a backup of your insurance papers, either on the computer or in the form of photocopies. In case, if you lost your insurance papers or can’t find it on time, then you will face a delay in the claim settlement process.
  1. Some minor issues that may delay the cashless treatment or claim settlement process:- 
  • Failure to note the exact time and date of discharge.
  • Failure to inform the third party to prepare relevant documents and share the same with the health insurance company.
  • Failure to get and follow up the proper information with the third party and the insurance company. 
  • Failure to update your lifestyle habits or provide inaccurate information about the health condition.

In Conclusion

These are the five principal reasons why the claim settlement process is delayed. And most of the reasons are relatively minor and very procedural in nature. You can avoid these mistakes by taking some steps. You should fill your policy claim form yourself, to avoid any incorrect information provided. You have to double-check your application form and documents to see if there are any minor mistakes. 

You should provide all relevant and accurate information to the insurance company. You should go through your policy thoroughly to know where you stand. You have to disclose all kinds of health conditions you have or any treatment with your insurance provider. You should update your insurance provider about your lifestyle habits. 

Last but not least, you should not delay in filing your claim and keep your documents safe and secure and well organized. So, your knowledge and precaution for these mistakes help you to avoid delays in the claim settlement process. And it ensures that your health insurance claim will settle in a timely and organized manner.

FAQs: Delays in Health Insurance Claims

What is meant by deductible in health insurance?

A deductible amount is a certain amount that an insured has to pay before the insurance service provider starts paying. For example, if you have a health insurance plan of Rs.5 lakhs and the deductible opted for it is Rs.50,000. In case you admit to the hospital and the medical bill is for Rs.3 lakhs, then you will pay Rs.50,000 and the insurer will pay Rs.2,50,000.

You should remember one thing that the premium amount for high deductible policies is lower while the premium amount for low deductible policies is comparatively higher.

What are the tips to choose the best health insurance?

Being a rational consumer, you should go for the policy which offers you maximum coverage and peace of mind in terms of financial burden during an unseen medical emergency.

Here are some tips to choose the best health insurance plan:-

Look for the right Policy Coverage:- Before choosing a health insurance policy, you should ensure that policy will provide you comprehensive medical coverage. It includes ambulance charges, in-patient hospitalization, surgery charges, critical illness cover, nursing charges, doctor's fees, maternity benefits, cashless treatment, daily hospital cash benefit, etc. You should go through some factors such as sub-limits, waiting period, etc.

Flexibility to Add New Family Members:- While buying a family healthcare plan, it is always a good practice to ensure that you can include a new family member without any problem.

Check the Waiting Period clause:- Don't forget to check the waiting period for the pre-existing diseases in your plan. Most of the healthcare insurance policy covers specific treatments such as hernia, sugar, etc., but after the particular waiting period.

Focus on Lifetime Renewability Plan:- Ensure that you check the number of years that your family health insurance remains validated. Check whether it offers limited lifetime renewability or not. Always go with a family health insurance plan that offers a lifetime renewability option. You can proceed with the same health plan in the years to come without the problem of buying another policy after a specific age limit.

Room Rent Limit:- Whether you choose a private room, semi-private room, shared room, etc it depends upon your policy. So, it is always good to choose the health policy that gives higher room-rent eligibility if you want to avoid extra payment from your hard-earned money.

Is it worthwhile to invest in a health insurance policy?

Health insurance can reimburse the insured for medical expenses and bills from any kind of illness or injury. The essential health benefits include:-

i.) It protects you from unexpectedly high medical costs.
ii.) You get free preventive care like vaccines, screenings and health check-ups.
iii.) You receive outpatient care too.
iv.) Treatment in the hospital for inpatient care.
v.) Coverage for prescription drugs and lab tests.
vi.) Services and devices to help you recover if you are injured, or have a disability or chronic condition.