National Insurance Awareness Day: 8 factors to consider when filing a health insurance grievance

With rising expenses of health care, penetration of health insurance is growing and people expect that all their expenses towards major illnesses will be taken care of through health insurance.

They feel aggrieved when such claims are rejected because of complicated procedures. Policyholders feel handicapped and grope in the dark. This market lacks a helping hand or support system.

Policyholders are already in crisis due to the hospitalisation of loved ones and they face another crisis on claim rejection. On short notice, policyholders had to arrange the funds to meet hospital expenses.

We have tried to list down all major grievances faced by health insurance policyholders, the list is given below :

1. Rejection of claim on account of non-disclosure of pre-existing diseases.
2. Rejection of claim on account of non-standard method of treatment.
3. Rejection of claim on account of treatment at an unauthorised hospital.
4. Partial settlement of a claim with no explanations.
5. Rejection of claim due to exclusions.
6. Claim rejection post policy port from one insurer to another.
7. Claim rejection due to late information and submission.

These are common reasons and need to be escalated as per the grievance matrix of the insurer. As policyholders, you need to follow the steps listed below :

1. Insist on a written explanation of your grievance. Write to the claim support team about your problem and seek their answer. Insist on a claim registration number.
2. Once your complaint is registered then send at least three reminders on desired explanation.
3. Identify the problem. Each insurer has a customer help desk, call them and seek answers to your questions.
4. Once your problem is identified then check authenticity. It is the job of the insurance company to ask questions and doubts. You have a responsibility to give reasons why a claim needs to be paid as per policy terms and conditions.
5. Most claims are rejected based on non-disclosure of pre-existing diseases. Please note that when a patient is hospitalised in an emergency the hospital asks for the previous history and most of the time the attendant gives history as observed or heard. For example, having a headache for the last two years or having anxiety/blood pressure/knee problem/back ache/sinus. These are written on admission records and the insurance company rejects the claim. In such cases, policyholders need to clarify that these problems are observed but there has not been any medical diagnosis or medication. Such clarifications lead to claim settlement.
6. In the same way, port policy suffers due to non-disclosure because we assume that such history will be taken from the previous insurer but the new insurer is accepting your risk based on proposal form and declaration made. If you have a grievance on the port policy then you must remind the insurer that they must take previous records from the old insurance company. Being aware of your rights would ensure that your claim is paid.
7. If your policy is serviced through TPA then ask for a written explanation. Then provide all documents as desired by them. Your clarity and speed would lead to early resolution.
8. In case you have a problem with partial settlement then ask for a written explanation of unpaid expenses. Mostly such demands lead to the settlement of the balance. But you should be willing to accept at least a 10% deduction towards consumables. if the deduction is more than 10% then you have all right to escalate.

Good documentation, record keeping, and prompt reply would ensure an early resolution but is necessary to be honest when you are applying for health insurance. Please read the proposal form as well as the terms and conditions so that your grievances are minimal.

Shailesh Kumar, co-founder & insurance head, Insurance Samadhan