5 Hidden Clauses in Indian Health Insurance Policies That Stop You From Getting a Cashless Claim – Full Guide

The common reason for buying health insurance is to ensure that in the event of a medical emergency, the insurance company takes care of the hospital bills via a cashless claim.

But unfortunately, thousands of policy holders find out that just holding a policy does not assure that there will be any success in filing for a cashless claim.

A majority of cashless claims disputes do not result from treatments that have been excluded, but rather the lack of knowledge about some important information buried within the terms and conditions of a policy.

The Waiting Period Trap

The waiting period is one of the most widely misunderstood parts of health insurance. When people buy insurance policies, they presume that all diseases are covered from day one of the policy term. On the contrary, most health insurers have waiting periods for specific diseases and pre-existing conditions.

Take, for instance, diseases like hernia, cataract, joint replacement, or kidney stones; these diseases become eligible for coverage after a period of time.

In case of hospitalisation during the waiting period, the health insurer would deny the claim even if the health insurance is still in force. This is why checking waiting-period conditions before purchasing a policy is extremely important.

Non-Disclosure of Medical History

Insurance companies use the information shared while making the policy to assess the risk. Sometimes even a small thing might cause issues later.

In case the insured doesn’t share details about his/her existing diseases, surgery history, treatment, smoking history, or other illnesses, it will be considered material misrepresentation by the insurance company.

When an investigation of claims is being made, it becomes necessary for the insurance company to check the medical history of the insured person.

In case of inconsistencies, the claim of the insured person in terms of cashless health insurance will be rejected due to incomplete disclosure.

Hospital Network Restrictions

Not everyone understands that cashless admission requires the network hospitals. An insurance plan could cover almost everything, but cashless admissions are provided only at hospitals which have a tie-up with the insurance company or Third Party Administrator (TPA).

If the treatment is availed at non-network hospitals, the patient will have to pay first and then make a claim later.

This does not mean that the claim will be rejected, but the cashless facility offered by the insurance companies will be missed out. It is always advised to check the network hospitals prior to treatment.

Room Rent Limits Can Trigger Larger Deductions

The room rent restriction is one of the costliest clauses which are concealed. Most of these polices state a cap on the room category or daily room rent.

In case the person opts for a higher room category, not only is the reimbursement of room rent restricted but the expenses related to the doctor, nurses, and procedures also get reduced proportionately.

It has a major impact on the amount of the final settlement. It is after getting their cashless health insurance claim approved with a deduction that many people come to know about this clause.

Pre-Authorization Delays and Documentation Issues

Pre-authorization is always necessary for cashless claims. The hospital will provide information regarding the treatment procedure, diagnosis report, and the cost estimates for the same.

In case there are incomplete documents, unclear diagnosis reports, or the delays in getting an approval, then the insurance company may withhold the authorization process temporarily.

Some cases are such that the treatment will take place, but the patients have to pay up front.

Though this is not technically considered as a rejection, document-related problems form one of the most frequent causes of cashless claim problems.

Why Cashless Claims Get Delayed Even When Treatment Is Covered

However, most claimants think that any kind of issue encountered with claims must be due to fraud or some kind of malpractice by the insurance companies.

The reason for such issues is usually a need to obtain additional evidence on the validity of the claims.

A medical necessity review, an assessment of the policy conditions, waiting periods, as well as documentation, are some of the things involved in the process.

What Policyholders Should Check Before Buying Insurance

When buying any health policy, the consumer must study the policy terms in detail instead of concentrating on premium costs alone.

The smaller the premium cost, the larger could be the waiting period, restrictions on room rent, or exclusions in the health policy.

By analyzing the policy language, comprehending the exclusions, and posing some queries, you can avoid future claim disagreements. After all, a health insurance policy is a contract at its very core.

How IRDAI Is Pushing for Greater Transparency

There have been a number of changes brought about by the Insurance Regulatory and Development Authority of India to enhance the levels of transparency and protection of policyholders. Disclosures and policy terms have become clearer for insurers.

It is the obligation of the policyholders themselves to understand important terms before buying insurance. Knowing about an issue is the best defense against any disputes arising from claims.

Conclusion

A health insurance policy can give you financial security during medical emergencies, but that will be possible only if the policy is well understood.

There are numerous cases where there have been claims rejection and delays due to ignorance of various clauses, disclosure of certain things, network limitations, and conditions in the policy rather than because of non-coverages.

It will help save a lot of hassle during the medical emergency by understanding the policy terms before being hospitalized.

The biggest blunder in health insurance is understanding the policy terms after being hospitalized.

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