Verify health cover extent before buying insurance

 Recently, a Mumbai senior citizen received his Mediclaim amount, but minus a small sum which the insurer termed as pre-hospitalisation expenses. The 72-year-old consumer, who holds a joint policy with his wife, had been asked by the surgeon to procure certain medicines worth Rs 560 the night before his cataract operation. Although the surgeon issued a certificate saying the prescribed drugs were used during his hospitalisation, the bill amount was not reimbursed.
    This, even as insurance officials say that health policies usually cover pre-hospitalisation expenses up to 30 days before admission and 60 days after. Some insurers offer an extended limit of 60 days before and 90 days post-hospitalisation. There are also schemes where a flat 3-5% of hospitalisation expenses are paid for the period.
    While rejection of health insurance claims is not unheard of, consumer organisations say, sometimes, insurance companies withold a portion of the claim amount too.
    K S (Kaka) Samant, general secretary at General Insurance Pensioners’ Association (western zone), says an amount could be rejected on the grounds that the prescription was not connected to hospitalisation, or that particular illness or disease. “If your claim is for Rs 10,000, generally you will not get the entire sum. Something is reduced.’’ Samant points out a case where a patient was sent from one hospital to another by an ambulance for an MRI. But the ambulance charges were not reimbursed, citing that they are not covered in the policy. “Like this, several things are excluded.’’ V M Oza, honorary director, complaints, at Ahmedabad’s Consumer Education & Research Centre, says exclusions are mentioned in policy documents. Consumers are advised to carefully consider them before signing up.
    Industry officials TOI spoke to say that claims are settled based on supporting documents. According to a senior executive at a Delhibased third party administrator, which processes insurance claims, expenses before hospitalisation, like tests and diagnostics that lead to in-house treatment, are payable. He says, “But suppose you go for a comprehensive checkup, then it is not.’’ A senior Mumbai insurance official adds that sometimes claims are rejected if a consumer picks up more medication than prescribed or makes claims for expenses before or after the stipulated time limit. Samant, however, says companies insist on furnishing details and delay payment. Delayed payment is a violation of the Insurance Regulatory and Development Authority (Protection of Policyholders’ Interests) Regulations, 2002. In case one is unable to get redressal, consumer organisations advise approaching the insurance ombudsman with claims-related grouse.

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