These important limitations of your coverage may have an impact on health insurance claims.

These important limitations of your coverage may have an impact on health insurance claims.
These important limitations of your coverage may have an impact on health insurance claims.

In NEW DELHI: A health insurance policy is a necessity given the escalating expense of medical care, but it’s important to understand the potential restrictions before buying insurance because they can vary from policy to policy.

There is a waiting time after purchasing health insurance, so your protection doesn’t begin right away. This restriction guards against the abuse of such insurance to pay for existing conditions and anticipated immediate medical expenses. However, even during this time, accident-related medical costs are covered.

After a 30-day waiting period, most additional ailments are often covered in full. In addition, depending on the policy selected, coverage for specific pre-existing conditions, such as diabetes, hypertension, or heart disease, may be subject to a waiting period of up to three years.

Sub-limits clause in policyholders’ policies :-

The sub-limits clause in policyholders’ policies is a restriction that frequently takes them off guard. Benefits are limited under a sub-limit clause in health insurance for a number of conditions. For instance, even though your policy’s maximum amount of insurance is 5 lakh, there can be a sub-limit on the room rent in the event of hospitalisation, say 1% of the maximum amount of insurance.

If this were the case, your full sum insured would not be sufficient to cover the cost of renting a room, and you might only have the option of selecting a shared room rather than a private one in order to avoid having to pay the difference out of pocket. The cap might also apply to other costs like ambulance fees, medical visits, etc.

Sub-limits clause in policyholders' policies
Sub-limits clause in policyholders’ policies

Co-payment: To give policyholders lower premiums, many insurance contracts include a co-payment clause. Policyholders in such a situation pay a percentage of the medical bill when filing a claim. “ Co-pay refers to the portion of the bill that the policyholder is responsible for paying out-of-pocket.

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Hospitals in the network :-

Every health insurer has a partnership with a select number of hospitals around the nation, which they favour over other hospitals when resolving claims. For a simple claim process, these insurers prefer and suggest policyholders use one of these hospitals for their medical care.

Every insurer publishes a comprehensive list of network hospitals where patients can receive medical care. These institutions are known as network hospitals.

While receiving care at a hospital that is not in the network is also an option, the claims process won’t be as straightforward in those situations. Also available in network hospitals is cashless claim settlement, where the insurer pays the hospital cost directly.

Hospitals in the network
Hospitals in the network

The policyholder must first pay the whole cost out of pocket in a non-network hospital before filing a claim with the insurer for reimbursement, as such a facility is not available there.

Receiving medical care in a network hospital is usually preferable and prudent, especially when a pre-planned hospitalisation is involved. Only in unavoidable situations should a non-network hospital be thought of as a viable choice.

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Incorrectly entering the information Incorrect information on the proposal form or a minor inaccuracy with regard to pre-existing conditions or other insurance policies may prevent the insurance company from covering your hospital costs. Because when you purchase an insurance, the insurer runs the risk of having to pay your medical expenses.

This avoids undue disruption brought on by the policy’s cancellation or the denial of submitted claims. Make sure the name and information on your policy match what is on your Aadhar card, Pan card, and other KYC documents. If you enrol in a business health insurance plan, there’s a potential that your employer or HR team workers will add your name incorrectly or forget to include your family members, she added. Today, pay attention to the small details to avoid unpleasant surprises later.

The bottom line, according to Mint, is that by being aware of these important limitations, you may choose health insurance wisely and avoid being taken off guard even after spending money on it. In conclusion, pick a policy with a shorter waiting period, stay away from sublimits and co-payment provisions, and confirm that your selected hospital is included in the insurer you select’s network of hospitals.

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