I welcome you all to a very, very informative article, which is about various clauses which may be there in your health insurance policy. Now, why is this article really important? Because it may happen that you have paid a lot of premiums towards your health insurance policy. But when it comes to claiming the policy, your claim may get partially or fully rejected if you are not aware of the clauses in your policy.
What is the Co-payment clause?
So let's give an example to further grasp this coupling phrase. Here we have Mr. Arpit, who deliberates extensively before making any financial decisions. But because he had to make a claim for his health insurance this time, he may have been in a little bit of a rush and purchased an insurance policy from this XYZ insurance company. And for that reason, the bill is now due. But despite this, Mr. Arpit is still content because he understands that the insurance provider would likely cover the majority of the expense. And now things start to change. Mr. Arpit has now changed into Mr.'s brochure as a result of his recent discovery of a copay provision in his insurance policy. What does the 20% co-payment that was indicated in the insurance contract mean? Always remember, if you're going ahead with an insurance policy, checking whether there is a copay clause in your policy is not a positive sign positive side is that you will have to have you will have to pay a relatively lower insurance premium. If it is stated that there is a 20% copay, out of the total bill amount, only 80% will be settled by the insurance company, whereas 20% will have to be settled by Mr. Arpit. The drawback is that you might have to fork over a sizable sum while paying the bill if the hospital bill is far higher than what your insurance will cover.
What is the Zonal Co-payment clause?
Let's go on to the following clause, the zonal co-payment clause, in order to better understand it. Mr. Arpit has once more purchased an insurance policy from XYZ Limited. Mr. Arpit currently resides in a resort, a Toluca location, in the Vidarbha region of Maharashtra. Now, normally, this insurance provider will respond, "Okay, Mr. You will be covered without a problem, but you must receive your medical care in the same area, ok? They are happy to receive a lesser premium amount in this area because, in general, medical costs are somewhat lower. However, suppose that Mr. suddenly declares, "Now I'm going to have my treatment elsewhere like Pune or Mumbai." Do you believe that the medical prices will be significantly higher in such locations? If you answered yes, then it is clear that this will be the case. And if that's the case, then, to put it simply, if this person receives medical treatment outside of the area covered by his insurance policy, a zonal co-payment clause will kick in, dividing the cost of his treatment according to the proportion specified in his insurance policy.Before we continue, I want to make sure that everyone is clear on one very crucial point: your insurance may include both a copay clause and a zonal copay provision, or it may just have one of them, or it may have neither of them. So, before making a final decision, please check your insurance coverage.
What are the permanent exclusions in health insurance?
Let's move on to the following crucial exclusions. So I guess Mr. Arpit is still up to some Motocross Madness for that. I have no idea what he is doing. Perhaps he believed that his insurance coverage covered everything, but please note that adventure sports are permanently excluded from your health insurance plan. Please be advised that your health insurance will not pay for these charges. The second is that you will also be subject to a permanent exclusion if you engage in any drug or narcotic abuse. And they'll also be forever excluded if you get any cosmetic procedures.
What is the Waiting period clause?
Let's move on to them. next clause which is called a waiting period clause. Now, what is this, assume that there is a person who is wanting to take up an insurance policy, he signs up for that, and within the next four or five days he is detected with asthma. In such a case, typically insurance policies will say that there is a waiting period of 30 days from the commencement of the policy. So, from the commencement of the policy for 30 days, his claim will not be accepted, which is nothing but a waiting period. Again, let me tell you, I said generally it is 30 days, and your policy can have a different waiting period. So please check your insurance policy, right. The second thing is that maybe a person decides that, okay, I want to take up a health insurance policy, and he goes for a medical test. And during the medical test itself, it is discovered that this person has some disease saying asthma. In that case, also, there could be a waiting period, which could be involved. But how much could be the waiting period, again, depends on your policy number one, and number two, in such cases, premiums will be typically higher, why, of course, the insurance company knows that there's going to be an outflow out there. And so typically premiums will be higher. And one more point that I would want to bring to your notice is that if you're talking about certain medical conditions, which are which don't fall into the emergency category, something like a cataract, in that case, the waiting period could be a shade higher, it could go up to almost even two years. Again, how much waiting period is there in your policy? Please check that first and then proceed?
How can someone help us?
Well, we did talk about the copayment clause, we talked about the exclusions, we talked about zonal co-payment, we talked about the waiting period, and there are three more clauses that we are going to discuss right now. And I'm sure you might be like, Oh my God, how on earth am I going to check all these clauses and then choose the right insurance policy? Is there some easier solution for that? And the answer is yes, ditto has got you covered. They can help you to give absolutely free consultations. And they will give you honest insurance advice, wherein their experts can call you at your convenient time. And they can help you to understand all the clauses which are there in either the life insurance or the health insurance policy. Once you're convinced that okay, this policy suits me the best once you're convinced that okay, I've understood all the clauses, they can also help you through the entire buying process and if there is a claim to be processed, they will also help you to settle the claim.
Number two, if you have an existing health insurance policy in that case, also, they can help you review your policy and they can also help you to change the health insurance policy. If you want to book your call with ditto, CLICK HERE Also wanted to tell you that ditto is backed by zero data.
What is the Room rent restrictions clause?
Let's move on with the next clause which is about the room rent restrictions. Okay, now, what is this about? Certain insurance policies will mention that most services rendered in your room, something like doctor's fees consultants fees or it could be like other diagnostic exams, will not be fully covered. If you're choosing a room that is higher than the room limit, which is mentioned in your insurance policy.
I'll give you an example. Again, we have Mr. Arpit and we have the XYZ insurance company from whom he has taken the insurance policy. Now, it was very clearly mentioned in his insurance policy that the room rent limit is rupees 5000, but he chooses to go ahead with a room rent of rupees 10,000. Now what all things are there in his bill is the room rent then he has some doctor's fee consultatiofeesee some diagnostic examinations, but only half of the bill will be covered by the insurance company and half will have to be paid by now Mr.Arpit so I hope you have understood that if there is a room rent restriction in your insurance policy, then be aware that entire bill might not be settled by the insurance company if you exceed the room rent limit. So what is a better choice, better choices that selecting an insurance policy, which does not have such a restriction? n.
What are the steps that we should do in case we have to submit a claim?
Let's move to the next point which is about cashless claims. But to understand cashless claims, let's divide the discussion into two parts. One when we are talking either about plant treatments, or number two, where it is about emergency situations. First, let's start with plant treatments. In this case, what needs to be done if you want to go out with a cashless claim? In that case, at least two to three days before the decision date with the hospital for your surgery or whatever, you need to first go to the insurance desk at the hospital. Of course which hospital is in the network of that specific insurance company right. So first you go to the insurance desk, you submit a copy of your insurance policy you give your ID proof you give them the initial diagnostic reports and any other documents if they are demanded by the insurance desk you need to give all of these to the insurance desk when at least two to three days before the planned procedure in the case they will go ahead with the-authorization and if there-authorization is done, then you need not pay even one rupee while you are being discharged. Okay, this is about planned treatments.
What about emergency situations, of course, you can't pre-intimate them. But in case of emergency situations, whenever the patient is admitted, within 24 hours from the date of admission, you have to intimate the same to the insurance company. If you don't do so, if 24 hours lapse, then it will be more of a reimbursement rather than a cashless claim. I hope this point is also clear. But what if you don't have a cashless claim? What if you have a reimbursement claim only in the policy itself, in that case, what needs to be done is that the discharge is done within 15 to 30 days of the date of discharge, or in some policies, it is given within seven days of the date of discharge, you should initiate the claim process can be initiated either online or from the Registered Office of the insurance company. Along with this filling up of the form you need to attach the reports you need to attach the original copies of the hospital bills, Doctor consultation report, ts, and diagnostic reports. And if any other document is required, I hope all the basic points about cashlesclaimsim and reimbursement claims are absolutely clear.
How to handle claim rejections?
Moving ahead with the last point, assume that you go aheawithor a claim and you submit the final document last document for the claim. What happens within 30 days of the last document submitted the insurance company either has to settle the claim, or they can reject the claim. Or the big problem is that if your claim is rejected, then what?
Step number one, you can go back to the insurance company basically you drop an email to the grievance redressal cell, you can drop the email and if you don't receive a reply within 15 days or if you receive the reply but the reply is not satisfactory, then you can approach to the insurance ombudsman. Now, who is this insurance ombudsman, basically, he's a person who is like a mediator between people like you and me and the insurance company, your redressal can be done only up to rupees 30 lakhs. But if you don't receive a proper reply from the insurance ombudsman, then what then you can approach IRDAI, which is the insurance regulatory Development Authority of India, you can call on this number 18004254732 or you can also drop an email to this email address complaints@irdai.gov.in. And unfortunately, if this also does not work, then you can knock on the door of the court. But of course, I hope you understand that this can be an expensive and time-consuming affair. So instead of going through this long process, it will be better if you choose your insurance policy correctly and get a good consultation for choosing the right insurance policy.
