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Health Insurance Claim Procedures Issues in India


		Protect Your Interest
		Claim Form to Be Sent to TPA
		Circumtances Under Which Claims Get Rejected
		Claims not Allowed-Some Case Studies

CIRCUMTANCES UNDER WHICH CLAIMS GET REJECTED

The main reasons for claim not being passed in full are :

Insured has preexisting disease and it was already mentioned in policy document as an exclusion.
The specific diseases are not covered under the policy
Disease is a preexisting disease and it was not revealed by the insured at the time of issue of policy.
The main reasons for claim being passed in part are :
Some of the tests conducted/treatment were not relevant to the disease for which patient was admitted.
Some costs like consumables are not payable by the insurance company. Examples are :-

With a view to cover some of these payments some TPA's insist that 5% of the hospital bill will be paid by the patient. You should not be surprised if you are asked to pay 5% of the bill even if you are covered under cashless scheme. In the event of consumables are not 5% or more than 5% there is good possibility that you may get part of this paid to you at time of finalization of their claim.

As a customer you should see that information being given at time of admission into the hospital, discharge certificate, claim form is consistent. Any follow up letter being sent to the insurance company should be well drafted and consistent to the claim lodged.

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