Health insurance policyholders may not find their claims getting settled by insurance companies at all times. Sometimes the full claim gets rejected while at times, partial claims are settled. There could be different reasons for the claims to get repudiated by insurers. “Claims get rejected due to various reasons. As per our observations over the past two years, claims get rejected for hospitalization not being warranted i.e, the ailment could have been treated on an outpatient basis,” says Satish Gidugu, CEO and Whole Time Director, Medi Assist.
In recent times especially after the outbreak of Coronavirus, the claim settlement experience for the policyholders does not look to be satisfactory. Gidugu shares with us the Covid-19 claim scenario – Since 2020, COVID claims saw a steep rise and we also noticed that claims got rejected because people opted for hospitalization instead of opting for treatment under home care.
Health insurance policies come with a fine print that policyholders often miss reading, a considerable number of home care claims were rejected as certain policies did not cover home care. When it came to COVID vaccination, claims got rejected as a lot of policies did not include a COVID vaccination cover. COVID-positive patients who received treatment and isolation services at hotels saw their claims getting rejected as this was not covered under insurance policies. We also observed that inpatient treatments made through the antibody cocktails were rejected as they did not require hospitalization.
Kapil Mehta, co-founder, SecureNow also echoes similar reasons leading to rejection of Covid-19 claims – The main reason for rejection of claims, particularly Covid claims, is that the insurer felt hospitalisation was not warranted. The second issue has been partial claim settlement because the hospital charges were more than the stipulated rates. The third reason continues to be that of pre-existing conditions.
“For a smooth claim settlement the most important thing is to make sure the hospital clearly outlines the need for hospitalisation. Also, buy a highly rated product with no room rent restrictions and a waiting period of more than 2 or 3 years. Finally, work with intermediaries that understand the claims process and know how to address questions that insurers raise,” suggests Mehta.