These major restrictions in your policy can affect health insurance claims

New Delhi: Having a health insurance policy is a must amid the rising cost of medical care, but before purchasing insurance it is essential to understand the limitations that may apply and vary from one policy to another. here they are:

waiting period: When you buy a health insurance policy, your coverage doesn’t start right away. This limitation protects insurance companies from misusing such policies to cover pre-existing illnesses and foreseeable immediate medical costs in advance. However, even during this period, medical expenses due to accidents are covered. Coverage against most other illnesses begins largely after a 30-day waiting period. Furthermore, coverage for certain pre-existing illnesses, such as diabetes, high blood pressure or heart disease, can come with a waiting period of up to three years, depending on the policy chosen.

Sub Boundaries: A limitation that often surprises policyholders is the sub-limit clause in their policies. The sub-limit clause in health insurance defines benefits for specific conditions. For example, while your security deposit according to the policy can be R5 lakh, there may be sub-limit for room rent in case of hospitalization, say 1% of the guaranteed amount. In such a case, the full guaranteed amount will not be available to cover the cost of the room rent, and you may only be able to opt for a shared room instead of a private room, lest you pay the difference out of your pocket. Likewise, it can be capped at other expenses, such as ambulance fees, doctor fees, etc. It is best to choose a policy that covers all benefits up to the guaranteed amount, and many policies come with this feature.

Joint Payment: Many insurance policies come with a co-pay clause to offer policyholders cheaper premiums. In such a case, the policyholders pay a part of the medical bill while submitting the claim. “Co-pay is that part of the bill that the policyholder has to bear as an out-of-pocket expense. While this lowers the premium, making the policy affordable puts an additional burden while making a claim. For example, if the policy includes a clause 20 per cent co-pay, the total cost of medical treatment comes R2 lakh, then the insured will have to pay R40,000 while the insurance company pays the remaining balance R1.6 lakh. While this may work for some policyholders, especially seniors whose premiums are too high, it may not work for others. It is often better to choose a policy without a co-payment requirement if one can afford it, said Amit Chhabra, Head of Travel and Health Insurance,

Network Hospitals: Each health insurance company has a relationship with specific hospitals in multiple locations in the country, which they prefer over other hospitals when settling claims. These insurance companies also love and advise policy holders to choose one of these hospitals for treatment for a hassle-free claim process. These hospitals are called network hospitals, and every insurance company publishes a complete list of network hospitals where one can avail medical treatment.

While one can also benefit from treatment in an out-of-network hospital, the claim process in such cases will not be smooth. Furthermore, one can also opt for cashless claims settlement at network hospitals where the insurance company pays the medical bill directly. However, such a facility is not available in a non-network hospital as the policy holder must pay the full amount out of pocket first and then submit a claim to the insurance company for compensation. It is always better and wiser to get medical treatment in a network hospital, especially in the case of a pre-planned hospitalization. A non-network hospital should only be considered an option in unavoidable emergencies.

Fill in the incorrect information: Wrong information on the proposal form or a slight deviation in the details regarding current health problems or other insurance plans could result in the insurance company withholding your hospital expenses. The reason is that the insurance company risks paying your medical bills when purchasing the insurance policy.

Priya Deshmukh-Gelbel, chief operating officer of ManipalCigna Health Insurance, said, “The relationship between the insurer and the insurer is built on principles of honesty and transparency and, therefore, entails the insured sharing all necessary details without prejudice as to how trivial they seem. This prevents undue chaos. resulting from policy cancellation or denial of claims made Ensure that your name and details in the document match those mentioned in KYC documents including Aadhar Card, Pan Card, etc. Members may incorrectly add your name or miss adding your family members Be careful about details today to prevent unexpected grievances later. To avoid confusion during billing, the insured should also check that the doctor in hospital bills mentions their details accurately.”

Take mint: Knowing these key limitations, you can make a wise decision when choosing health insurance, ensuring that you are not caught off guard even after investing in health coverage. To sum it up, choose a policy with a shorter waiting period, avoid sub-limits and co-pay terms and make sure your preferred hospital is on the list of hospitals of the insurance company network of your choice.

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