7 Things to Ask Your Insurance Company

This article first appeared on India Infoline.

While we all hope and pray to enjoy a healthy, long life, medical care is something we do require at some point in our life. The unpredictable, unforeseen medical expenses can mean extra financial burden in this day and age. Having a health insurance is best way to cut down these expenses. A health insurance covers these charges and provides you with risk coverage against unpredictable medical emergencies. Hence, it is crucial that you choose the best health insurance plan for you and your family.

You will never know if you do not ask! To select the most suitable health insurance policy, it is essential to understand the fine prints of your policy and get clarity on factors that really matters while a selecting the best option. Here is a list of 7 things which you should discuss with your insurance agents before taking the plunge:

  1. Does your insurance company offer cashless hospitalization?

Most of the health insurance companies offer special schemes and plans which suit your individual healthcare requirements. As per Insurance Regulatory and Development Authority (IRDA) guidelines, if your insurance company has tie-ups with hospitals (Network hospitals) then you do not have to pay for taking treatments in those hospitals. This policy is called ‘Cashless Hospitalization.’ The expenses under this policy are settled directly between hospital and health insurance company with the help of a Third Party Administrator (TPAs) and does not require your involvement .Ask your insurance company if they facilitate cashless health insurance policy or not.

  1. How established is their hospital network?

As per your policy, the list of network hospital and doctors may vary. Ask for a detailed list of hospitals where you can avail your health insurance service. In case of reimbursement health insurance schemes, you can get admitted to any hospital and claim insurance later, which could be quiet cumbersome and time consuming. Cashless health insurance policy, on the other hand, required you to visit only the network hospitals. But once admitted the entire process is hassle-free. All you need to do is provide details of your policy and rest of the process is carried out by TPA.

Also, enquire if you can continue to consult your family doctor. If no, ask them to present you with doctor’s name who you can seek consultancy from.

  1. What does your health insurance policy cover?

 More importantly identify what your policy does not cover as that is where the maximum disconnect happens. We often think that our insurance policy is like a credit card where we just swipe the card and things are taken care of. This is not the case. It is important to understand the fine prints, particularly, what percentage of your expenses would be covered for different services such as hospital rooms, ambulance, general treatment amongst others.

This plays a decisive role while choosing health insurance. Ask for descriptive information about covered and uncovered treatments and diseases. Your health insurance policy should ideally cover:

  • Maternity care and what fraction of the same
  • Accident and ambulance
  • If you need any special care, such as home care or traditional treatment therapies like ayurveda, naturopathy and homeopathy, confirm that it is covered in the policy
  • It should not have unreasonable restrictions on the quantum of payment for any category of expense like surgery charges or room charges
  1. What are their pre-existing conditions?

Many health insurance policies have certain pre-existing conditions which should be fulfilled in order to claim your bill. It might include informing the insurance company within 24-hour of incident or submitting a necessary document. Few policies have limit on number of times you can file a claim. Ask distinctively about these conditions, as failure to meet any of the conditions may deny your rights to claim.

It is equally important to understand that how a pre-existing condition is defined by the insurance companies as this could be a serious source of dispute in future. For instance, if at the time of medical tests during an emergency, a patient is reported to have high sugar levels of which he was not aware at the time of enrolling for the policy, there are chances it might be construed as a pre-existing condition. Hence, it is essential to have absolute clarity on the definition of pre-existing conditions.

  1. How is your premium calculated?

Several factors come along while determining your premium. Your age and previous medical history play major role in deciding the premium amount. Few insurance policies have “out-of-pocket” plan cost where few expenses not covered under the policy are reimbursed by the insurance companies partially. Ensure to acquire information about the expenses deductible and percentage reimbursement for such plans. Also seek clarity on how often you would be required to pay the premium. Ask your insurance agent for a premium matrix to help you understand clearly how premium charged would vary when different variables are considered.

  1. How is the claim reimbursement process handled?

Here comes the most critical part of any insurance policy: the claims reimbursement process. Clarity is extremely important on the how the insurance company would handle the reimbursement process. Turnaround time involved in claim settlement process should be clearly understood. The speed and accuracy of approvals at the time of discharge is highly critical. Many insurance companies are now adopting technology solutions to ensure that there is accuracy in maintaining records to avoid unnecessary delays at the time of claim settlement. Check with your insurance agent the efficiency with which the reimbursement process is handled by your insurance company.

  1. How responsive is your insurance company?

The insurance company representatives should be easily accessible and clear in their communications with the policy holders during the claim reimbursement cycle. If the entire claim amount is not processed, policy holders should get answers to their queries such as reason behind the same and what recourse do they have in such situations.  Instead of relying on a call centre number, explore other options for collecting information for getting such clarifications. A web or mobile based access to all stages of interactions with the insurance company/ TPAs, in both cashless and reimbursement claims, could be a better approach. It would also be advisable to ask in advance the approach your insurance company will take to resolve any possible disputes in future.

As the old saying goes, ‘Health is the greatest wealth.’ While it is important to adopt a healthy lifestyle to enjoy this wealth, it is equally important to plan for unforeseen health emergencies. This smart planning can help in avoiding unnecessary financial burdens while ensuring the best in class medical attention in the most hassle free manner. The technology has come to our rescue in enhancing the quality of care and experience once hospitalized. If the administrative authorities could embrace the latest technological developments, the process of hospitalization and insurance settlement would become hassle free for those taking care of the patients at the crucial juncture. Dedicate some time in analyzing policies from different perspectives and use your wisdom to make the best decision for you and your family.


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