Home / Money / Personal Finance /  How to get the maximum claim from your health policy

Hospitals don’t always evoke nice images: Think of sickness, diagnostics, physiotherapy and surgeries. Add to this the huge medical costs of such treatments, and hospitalization turns into a dreary world. That’s the reason why most people take a health insurance policy—It provides them financial support and helps them meet the exorbitant expenses associated with a planned course of treatment or an unplanned medical emergency.

However, many policyholders believe that insurers are bound to settle their claims in full. That isn’t the case though. Insurers only settle claims based on the terms and conditions set forth in the insurance policy document. Moreover, they adhere to a pre-fixed rate recommended by the General Insurance Council (GIC) in India when settling such claims.

Here are some ways that can help you get the maximum claim from your health policy.

Comprehensive health policy: Most health insurance policies come with a deductible, commonly known as super top-up plans. In such plans, there is a threshold limit (deductible) on payments. Before your health policy fully covers your medical costs, you must reach that threshold limit.

Depending on your plan, your annual deductible can be a few thousands or even lakhs of rupees. In other words, a super top-up plan typically works on a cost-sharing basis. It means the plan does not bear the entire cost; only a part of it is covered based on your deductible.

However, a comprehensive health policy covers all types of medical costs without any deductibles. It covers a wide range of medical expenses, including the cost of hospitalization, etc., without the policyholders having to pay for these from their pockets.


There are questions over claim settlement done by traditional branch-led model,
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There are questions over claim settlement done by traditional branch-led model,

Multi-year health policy: When you buy a multi-year health policy, the premium remains the same throughout the entire policy period. This way, you are protected from any subsequent premium adjustments made by an insurer during the time the policy is in force. Typically, policyholders have to pay multi-year premiums for up to three years in one go. And so, a rise in the cost of insurance won’t affect you for three years.

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Prawal Kalita, managing director, Marsh India, said healthcare costs are on the rise. One distinct advantage that a multi-year contract offers is the premium lock-in that one gets when opting for such a policy. “However, you need to weigh the financial and practical gains of multi-year policies when choosing them," said Kalita.

Terms and conditions: Insurance documents offer an in-depth explanation on the terms and conditions of the policy that can run into multiple pages, irrespective of whether it is bought online or offline. Most policyholders avoid going through the documents because they are too wordy, and this can prove to be costly during the claim process.

Room rent clause: Certain expenses are unavoidable if you are hospitalized and these include the fees paid to surgeons, consultant doctors, medical bills and charges for the operation theatre, etc. Most of these are taken care of fully by your health policy, The exception is the charges paid for the ward or room where you are admitted. Insurance policies set a limit on the charges that can be paid for this. If the insured person occupies a room that has a higher rent than what is mentioned in the insurance policy, it may result in deductions from the claim amount.

Ankit Agarwal, CEO and co-founder of InsuranceDekho, said most insurers generally allow basic or single standard private rooms under health insurance policy coverage. “You should always opt for a room with rent that meets the limit set by the insurer. Else, you can also opt for a policy without a room rent sub-limit or choose to go for an additional cover at an extra cost. It is essential to verify the room rent limit in a health insurance policy," said Agarwal.

Co-payment clause: This refers to a clause in the policy wherein insurers agree to pay a pre-fixed percentage of the claim amount since most health insurance policies don’t cover certain expenses.

Agarwal said, “You must choose a health insurance policy that does not have a co-payment clause. Besides, health insurance policies mostly do not cover costs associated with maternity, dental, and optical checkups or treatment. It also does not cover treatment arising out of consumption of intoxicants, voluntary organ donation, etc. In some cases, it is good to opt for add-on covers . For example, you can add a maternity cover to your policy to meet maternity-related expenses."

Claim settlement process: No insurance policy can serve its purpose until and unless it provides proper claim settlement to the insured. Indraneel Chatterjee, co-founder of Renewbuy, said, “There is a serious question around the claim settlement done by traditional branch-led model even today. It is better to go for a cashless facility regarding health claim settlement."

“Typically, insurers have a tie-up with network hospitals. Because of this affiliation, they manage to give discount package rates for frequent treatments to policyholders if they file cashless claims. Insurers and network hospitals offer discounts onlyon cashless treatment because this helps them manage the claims costs for several planned surgeries,“ said Abhishek Bondia, principal officer and managing director, SecureNow.in.

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Navneet Dubey

Navneet Dubey is a personal finance writer and artist. Over the past decade, he has written feature stories on insurance, financial planning, lending and borrowing.
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