1) The insurance regulator has said in a recent report that at present the process of cashless claims is long, and companies reduce the claim by 10 percent or more in the name of various charges. Why do policyholders not get the full claim?

Answer: There are several reasons why policyholders may not get the full claim amount in a cashless settlement. Some of the possible reasons are:

• The policy may have a deductible or co-payment clause, which means that the policyholder has to bear a certain percentage or amount of the medical expenses. For example, if the policy has a 10% co-payment clause, the policyholder will have to pay 10% of the bill, and the insurer will pay the remaining 90%.
• The policy may have sub-limits or caps on certain expenses, such as room rent, doctor's fees, diagnostic tests, etc. This means that the insurer will only cover these costs up to a certain amount, and anything above that will be the policyholder's responsibility. For example, if the policy has a sub-limit of Rs. 3000 per day for room rent and the actual room rent is Rs. 5000 per day, the policyholder will have to pay the difference of Rs. 2000 per day.
• There may be exclusions or non-payable items in the policy, which are costs that the insurance policy does not cover. These may include items such as consumables, personal care products, registration fees, service charges, etc. The policyholder will be responsible for paying these costs, and the insurer will not reimburse them.
• The policy may have waiting periods or pre-existing conditions, which are ailments or diseases that are not covered by the insurance policy for a certain period of time or until a certain condition is met. For example, if the policy has a waiting period of 2 years for cataract surgery and the policyholder undergoes cataract surgery within 2 years of buying the policy, the insurer will not pay for the surgery.

While these are some of the common reasons why policyholders may not get the full claim amount in a cashless settlement, the reasons may vary depending on the terms and conditions of the insurance policy and the discretion of the insurer. Therefore, it is advisable for policyholders to read and understand their policy documents carefully and clarify any doubts with their insurer before availing of cashless treatment.

2) What is the reason why the cashless claim is rejected?

Answer: There are a number of potential reasons why the insurer will reject the cashless claim. Some of the possible reasons are:

• The policy is invalid or expired at the time of the accident or the damage to the car.
• The treatment is being taken at a hospital that has no tie-up with the insurance company.
• The documents sent by the hospital are incorrect or incomplete, such as the pre-authorization form, the medical reports, the bills, etc.
• The disease or medical condition is not covered under the policy, such as pre-existing diseases, exclusions, non-payable items, etc.
• The pre-authorization request was delayed or not shared on time with the insurer or third-party administrator (TPA).
• The policyholder has withheld or given false information about their health status, medical history, or personal details.

3) Insurance companies do not cover many expenses during treatment. This type of trend has increased more since the Corona period. What should the policyholder do about this? Can such expenses be avoided?

Answer: The policyholder should be aware of the non-medical expenses that their health insurance policy does not cover. These are expenses that are not directly related to the treatment of the disease or injury, such as personal care products, registration fees, service charges, etc. The Insurance Regulatory and Development Authority of India (IRDAI) has provided a standard list of non-payable items for policyholders to understand what is usually excluded from their health plans. The policyholder can find this list on their insurer's website or in their policy document.

There are some ways to avoid or reduce such non-medical expenses during treatment. Here are some tips:

• Use non-hospital diagnostic centers for blood tests and imaging tests, as they may charge less than private hospitals.
• Buy generic medicines instead of branded ones, as they may have the same efficacy but a lower cost.
• Opt for a network hospital that has a tie-up with the insurance company, as they may offer cashless treatment and lower rates for medical services.
• Send the pre-authorization request to the insurer or the TPA as soon as possible to avoid any delay or rejection of the cashless claim.
• Choose a health insurance plan that has no or low deductibles, co-payments, sub-limits, or waiting periods, as these may reduce the claim amount or increase the out-of-pocket expenses.
• Review the policy terms and conditions carefully and clarify any doubts with the insurer before availing of the treatment to avoid any surprises or disputes later.

These are some of the ways to avoid or reduce non-medical expenses in health insurance. However, it may not be possible to eliminate them completely, as some of them may be unavoidable or unpredictable. Therefore, it is advisable for policyholders to have an emergency medical fund or a healthcare discount card to cover such expenses and reduce the financial burden.

4) Now the insurance regulator has said that it will arrange 100% cashless claims in collaboration with insurance companies. It will also speed up the claim settlement. How would this be possible?

Answer: IRDAI has said that it is working with health insurers to ensure 100% cashless claim settlement for all medical expense claims as soon as possible. This means that the policyholders will not have to pay anything out of pocket for the treatment covered by their health insurance policy, and the insurer will directly pay the full amount to the hospital.

According to IRDAI Chairman Debasish Panda, this would be possible by enabling common empanelment and interoperability with hospitals through the industry bodies, the Life Insurance Council and General Insurance Council. This will make the claim processing for health insurance seamless and frictionless for the policyholders. He also said that IRDAI is working closely with the National Health Authority to onboard more hospitals onto the National Health Exchange, which will facilitate the exchange of information and transactions among various stakeholders.

He also said that IRDAI is planning to launch new measures, such as long-term products, flexible plans for senior citizens, and new niche players, to deepen the market and smooth the insurance process. He also announced the launch of the first quantitative impact study to develop the proposed risk-based solvency framework for the sector and enhance the industry's risk management practices.

However, these steps may take some time to implement and may face some challenges from various stakeholders.

Viewer Questions

Question 1:

Ramesh Pawar, Dehradun, Uttarakhand

I have a family floater plan with a cover of Rs 5 lakh. I had undergone an operation for my wife's cyst. When it came time to pay the bill, the company rejected the claim in the name of chronic illness. Whereas this disease has been revealed only during treatment, What should I do?

Answer: Here are some tips you can take to appeal against the rejected health insurance claim in our country.

• Check your claim form and apply again. If your insurer rejects the claim, you should go through the denial letter and know the reason for the rejection. If the insurer states a discrepancy in the claim form, you must review the application again, rectify the mistakes (if any), and apply again.
• Contact an ombudsman: The government appoints the ombudsman to assist policyholders in resolving any problems they might be experiencing with regard to their claim rejection. You can write a written complaint to the ombudsman in your region with the details of your rejected insurance claim and information about your insurance provider.
• Provide sufficient documents: You should provide all the necessary documents to support your claim, such as medical records, wordings of the policy, and all the relevant receipts that will help to prove that your wife's cyst was not a pre-existing or chronic condition.
• Keep track of the communication: You should keep a record of all the communication that you have with your insurer or the ombudsman, such as phone calls, emails, letters, etc. This will help you to have evidence of your appeal process and follow up diligently.
• Follow up diligently: You should not give up on your appeal and follow up with your insurer or the ombudsman regularly until you get a satisfactory resolution. You should also be prepared to escalate your complaint to higher authorities if needed.

However, these steps may take some time and effort, and there is no guarantee that you will get a favorable outcome. Therefore, it is advisable to read and understand your policy documents carefully and clarify any doubts with your insurer before buying a health insurance plan or filing a claim for it.

Question 2: Sachin Parashar, Rohtak, Haryana

My parents are 60 years old. After my father's retirement, he did not have any health insurance coverage. Health insurance cover has to be taken for them. How and where can I get it? How much cover should I take?

Answer: Health insurance is very important for senior citizens, as they are more susceptible to illnesses and medical expenses. There are many factors to consider when choosing a health insurance plan for your parents, such as:

• The entry age and renewability of the plan: You should look for a plan that has a high or no upper age limit for entry and offers lifetime renewability, so that your parents can stay covered for as long as possible.
• The coverage and benefits of the plan: You should look for a plan that covers a wide range of medical expenses, such as hospitalization, daycare procedures, pre- and post-hospitalization, domiciliary treatment, critical illness, etc. You should also look for a plan that offers benefits such as cashless treatment, annual health check-ups, ambulance cover, etc.
• The exclusions and waiting periods of the plan: You should look for a plan that has minimal exclusions and waiting periods for pre-existing diseases, specific ailments, and co-morbidities. You should also check the list of non-payable items and sub-limits that may reduce the claim amount.
• The premium and sum insured by the plan: You should look for a plan that offers an adequate sum insured at an affordable premium. The sum insured should be sufficient to cover the expected medical costs of your parents in the future. The premium should be within your budget and not increase drastically with age.

These are various health insurance plans for senior citizens in India. You can compare these plans online or with the help of a financial advisor. The amount of cover you should take depends on various factors, such as your parents' age, health condition, medical history, lifestyle habits, expected inflation rate, etc. Generally speaking, you should aim for a sum insured that can cover at least 10 times your parents' annual income, or 50% of your net worth. However, this is just a rough estimate, and you should consult a financial advisor or an insurance expert before making a decision.

Question 3: Anil Sachdeva, 38 years old, Chandigarh

I have a clothing showroom. The family consists of a wife and two children. I haven't taken any health insurance yet. How do I calculate the cover? How much cover should I take?

Answer: I'm glad you are interested in buying health insurance for yourself and your family. Health insurance is a wise investment that can protect you from the high costs of medical care and provide you with peace of mind.

There are many factors that affect the amount of health insurance coverage you need, such as your age, health condition, medical history, lifestyle habits, family size, income, expenses, etc. However, there is no fixed formula to calculate the exact coverage you need. It depends on your personal preferences and risk appetite.

However, you should consult a financial advisor or an insurance expert before making a final decision.

Question 4: Rajan Chauhan, Jaipur, Rajasthan

There are a total of three members in my family, including my wife and son. I have taken a health insurance cover of Rs 5 lakh. What is a cheap and easy way to increase this coverage?

Answer: One of the cheap and easy ways to increase your health insurance coverage is to buy a super top-up plan. A super top-up plan is a type of health insurance plan that provides additional coverage to your existing health insurance policy when your hospitalization bill exceeds a certain limit, called the deductible. The deductible is the amount that you have to pay from your own pocket or from your basic health policy before the super top-up plan kicks in. For example, if you have a super top-up plan with a deductible of Rs 5 lakh and a sum insured of Rs 10 lakh and your hospitalization bill is Rs 8 lakh, then your super top-up plan will pay Rs 3 lakh (Rs 8 lakh - Rs 5 lakh) and your basic health policy, or you will pay Rs 5 lakh.

The benefits of buying a super top-up plan are:

• It is cheaper than buying a new comprehensive health insurance policy with a higher sum insured.
• It covers multiple claims in a year, unlike a top-up plan that covers only one claim above the deductible limit.
• It covers pre- and post-hospitalization expenses, daycare procedures, critical illnesses, and pre-existing diseases (with a waiting period).
• It offers tax benefits under Section 80D of the Income Tax Act.
• You can buy a super top-up plan from your existing insurer or from a different insurer. However, it is advisable to buy it from your existing insurer, as it will be easier for the hospital to coordinate with one insurer for your claim settlement.

Question 5: Chandrika Rai, Arrah, Bihar

I have a three-year-old health insurance policy. I am not satisfied with the service of my insurance company. When and how can I change this policy?

Answer: You have the right to change your health insurance policy to another insurance company at the time of renewal. This feature is called health insurance portability, and it allows you to switch to a new insurer without losing the benefits you have accumulated with your old insurer, such as the waiting period for pre-existing diseases, the no-claim bonus, etc.

You can compare different health insurance plans and premiums online or with the help of a financial advisor.

Question 6:

Jindal Ji, last question: If you are buying a health insurance policy for your family, what are the main points on which you should do your homework?

Answer: Buying a health insurance policy for your family is a very important decision that requires careful research and comparison. There are many factors that I should consider before choosing a suitable plan for my family's health needs. Some of the main points on which I should do your homework are:

• The coverage and benefits of the plan: You should look for a plan that covers a wide range of medical expenses, such as hospitalization, daycare procedures, pre- and post-hospitalization, domiciliary treatment, critical illness, etc. You should also look for a plan that offers benefits such as cashless treatment, annual health check-ups, ambulance cover, maternity cover, etc.
• The exclusions and waiting periods of the plan: You should look for a plan that has minimal exclusions and waiting periods for pre-existing diseases, specific ailments, and co-morbidities. You should also check the list of non-payable items and sub-limits that may reduce the claim amount.
• The premium and sum insured by the plan: You should look for a plan that offers an adequate sum insured at an affordable premium. The sum insured should be sufficient to cover the expected medical costs of your family in the future. The premium should be within your budget and not increase drastically with age.
• The claim settlement ratio and customer service of the insurer: You should look for an insurer that has a high claim settlement ratio and a good customer service record. The claim settlement ratio indicates the percentage of claims that the insurer has paid out of the total claims received in a financial year. A high claim settlement ratio means that the insurer is reliable and prompt in settling claims. The customer service record indicates the quality of support and assistance that the insurer provides to its customers. A good customer service record means that the insurer is responsive and helpful in resolving queries and grievances.

Justin Raj

Alpha Research Team