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The cost associated with hospital expenses is increasing tremendously. The rising healthcare costs have the ability to take a huge toll on one’s financial situation. In order to cover the spiraling expenses, individuals opt for a health insurance cover. Such a policy helps cover treatment cost during times of medical emergencies. Purchasing a health plan saves individuals the stress of having to arrange cash at the last moment.
About health insurance claims
A policyholder is eligible for a health insurance claims only if he / she has been admitted to a hospital for a period greater than 24 consecutive hours. The hospital bill has to be then submitted to the insurance provider for reimbursement. When the insured makes a claim, it means that he / she is requesting a reimbursement of the expenses incurred by submitting the detailed invoice of the expenses from a hospital.
Sometimes, there are exceptions to the 24-hour hospitalisation rule. Health insurance may be claimed during times when the insured is admitted for less than 24 hours. Such cases include cataract treatment, chemotherapy, prostate surgery, or any other procedure as specified by the insurance company. It is, therefore, important to check the treatments that are covered in your health insurance policy document.
Extent of claim coverage
Most health insurance policies cover expenses towards tests and diagnosis, drugs or medications, and treatment services. This list is known as ‘covered services’ and includes other services as well namely ambulance services, maternity care, pediatric services, and rehabilitation cost. However, it is important to note that this list varies from provider to provider. Certain services covered by a particular health insurance provider may not be covered by another. Hence, it is essential to review all the options and opt for such a plan that suits your requirements.
Claim exclusions
Often, you may have noticed that you are not reimbursed the total bill amount. This is because heath providers have certain exclusions.
Following are a list of hospital expenses that are not reimbursed to policyholders.
1. Consumable items
There are certain consumable items which do not classify as medical expenses. These items include bandage, cotton, antiseptic lotion, gloves, syringes, diapers, razors, and a few others. Such items do not qualify for health insurance claim as they are accounted for by toiletries and personal comfort items. Therefore, expenses towards the same will not be covered and will have to be borne by you.
2. Service charges and registration fees
There are numerous hospital services that are a part of your medical bill. These services include ward and Operation Theater booking charges, housekeeping charges, television and air conditioner charges. Some hospitals also levy registration fee that is charged at the time of patient’s admission. Additionally, there are other surcharges which are fees added to the existing cost of service. Most insurance providers do not cover such charges and hence, do not reimburse these fees.
3. Limit on room rent
Typically, 1-2% of the total sum assured is set as limit for room rent. If the actual room rent exceeds this amount, the policyholder has to cover the additional expense from his / her pocket. For example, if the sum assured of the policy is Rs. 2 lakh, then Rs. 4000 is covered per day as room rent (assuming a 2% rate). If you are admitted to a hospital room whose fee is greater than Rs. 4000, you have to shell out the excess amount from your own pocket. Therefore, it is advisable to check the cost of the room and compare it with the covered limit. Moreover, you may avail of the same treatment in a general ward for a lesser price.
The above-mentioned costs are not covered in your reimbursement. Hence, you do not receive the total amount that the hospital has billed you for. If you have opted for a cashless health insurance plan, these items may be billed separately to you. Again, this differs from provider to provider.
It is, therefore, important to read the terms and conditions of the health plan carefully before availing of one. Go through the list of items that are not covered under claims. Also, note that certain treatments and procedures are not covered in the plan. These include HIV/AIDS treatment, infertility, genetic disorders like Down syndrome or thalassemia, tobacco-related complications, dental treatment or surgery, expenses towards contact lenses or spectacles, gender change, and many others. The comprehensive list that is not covered in the plan is mentioned in the policy document.
Read the document carefully to know the inclusions and exclusions of the policy. By doing so, you will be in a better position to make a well-informed decision pertaining to your healthcare needs.