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If you have a group insurance policy from Star Health, your insurer might not settle a claim if you get admitted to a non-network hospital. Star Health insurance company informed its clients through an internal circular that, starting this year, the insurer cannot entertain any claim arising from a non-network hospital unless it is an emergency. 

In case of medical emergencies and accidents, one could avail treatment in non-network hospitals and the policyholder can claim reimbursement from the insurer.

"We have introduced this clause as the instances of claims from non-network hospitals increased over time, and we have no control over non-network hospitals, their billing, know-how, etc. Hence, the policy T&C got revised," told a senior spokesperson of Star Health to Mint on condition of anonymity.

The e-mail sent to clients reads, "We would request you to kindly go through our group insurance policy conditions with regard to admission in non-network hospitals which reads as under: Treatment in our network hospitals only, however in the case of medical emergencies and accidents, treatment can be taken in other Hospitals. In all cases, immediate intimation shall be given to our Call Centre within 24 hours of hospitalisation. Kindly be informed that any claim preferred in Non-Network Hospital cannot be entertained unless it is an emergency. You will understand that these claim papers are subject to scrutiny by statutory auditors and IRDAI regulatory audits. Hence we are left with no other option except draw your attention to this provision and to mention that this clause will be strictly important emended from 01 February 2022."

The clause was introduced in the group insurance policy last year and is mentioned under the terms and conditions of the policy document. 

Dr S Prakash, managing director, Star Health and Allied Insurance, said, "We are doing so for policyholder's benefit as we are not aware of the infrastructure, doctor's expertise, facilities available in non-network hospitals. So when a patient goes to a network hospital, we can verify whether the patient requires the particular treatment. We validate whether there was a need for such treatment, was surgery or ICU required. All these things are possible only if a patient goes to a network hospital."

The impact on policyholders

Experts have expressed concerns about the Star Health move. Mahavir Chopra, founder, CEO, Beshak.org said, "It seems the insurer is restricting its group insurance coverage largely to its network to control the process and payments for not only cashless claims, but all claims."

"This may not be a problem for people living in the cities where there may be enough and many hospitals around to choose from. However, people especially living in Tier 2 and beyond will now have to first look at the hospital network before planning any hospitalisation treatment, which looks difficult because the choice of hospitals is driven by the treating doctor consulted. This is a big change, and I hope there is enough awareness around this major restriction - so that customers are not left with a shock after the treatment."

Echoing similar views, Naval Goel, founder and CEO, PolicyX.com, said, "It's a little restrictive to policyholders although it won't affect the majority of the policyholders living in urban cities. However, it may affect people living in rural or suburbs as finding the nearest network hospital can become cumbersome." Besides, you might not get better internet facilities in rural areas to search for network hospitals.

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