What Issues People Face in Health Claims in India😧

When you subscribe to a health insurance policy, you expect it to act as a financial safety net during medical emergencies. However, the true test of any insurance policy comes at the moment of filing a claim. Unfortunately, the claim settlement process in India is often affected by challenges that can leave policyholders frustrated and financially strained.

Major Challenges in Health Insurance Claims😱

1. Documentation Issues~

• Missing or incomplete claim forms that lack essential details
• Absence of original bills and receipts from hospitals
• Insufficient medical records or incomplete diagnosis information
• Discrepancies between hospital bills and the treatments received
• Missing pre-and-post-hospitalisation expense proofs

2. Policy Exclusions and Waiting Periods~

• Pre-existing disease clauses that exclude coverage for conditions you had before buying the policy.
• Specific waiting periods for certain treatments or procedures.
• Sub-limits on room rent, specific procedures, or disease categories.
• Exclusions for certain medical conditions or treatments that aren’t covered at all.

3. Claim Processing Delays~

• Extended verification processes that go beyond stated timelines.
• Multiple rounds of additional document requests from insurers.
• Delays in receiving pre-authorisation for planned procedures.
• Slow communication between hospitals and insurance companies.
• Backlogs during peak seasons when claim volumes are high.

4. Network Hospital Limitations~

• Limited network hospital options in smaller cities and towns.
• Variations in empanelment across different insurance providers.
• Cashless facility denials despite being at a network hospital.
• Different procedures and protocols across hospital chains.
• Exclusion of certain departments or treatments even within network hospitals.

5. Billing and Coding Discrepancies~

• Hospital bills that don’t match pre-authorised amounts.
• Incorrect procedure codes used in hospital documentation.
• Unbundling of procedures to increase billing amounts.
• Non-medical expenses incorrectly included in treatment bills.
• Discrepancies between electronic and physical bills.

These issues can result in partial claim approvals or complete rejections, leaving you with unexpected out-of-pocket expenses.

We guide our customers at all levels from the time of procurement of the best suitable policy till the smooth settlement of claims😇