You may not get full claim against medical bills; Here’s why

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Amid the Covid-19 pandemic, the health ministry recently said that more than 70% of the deaths reported so far have occurred due to comorbidities. The data stresses the fact that a well-suited health insurance policy should be a part of your overall financial planning now.

While the purpose of health insurance is to act like a financial shock absorber that prevents your personal savings from the impact of expensive medical costs, some costs related to medical bills have to be borne by the policyholder despite carrying a cashless health card and availing of services at a network hospital.

Mediclaim Deductions 

Often, the deduction in medical claims occurs due to factors such as non-medical expenses, investigation charges, hospital room rent, etc.

“Health insurance policy covers expenses as per the inclusions of a policy contract which are primarily towards the patient treatment and not administrative costs. Certain non-medical expenses are not covered and hence it is crucial for the insured to know what coverage they have opted for,” Bhaskar Nerurkar, Head – Health Claims at Bajaj Allianz General Insurance, said.

Typically non-medical expenses are required to be paid by the insured which forms 8-10% of the bill amount. It is also important to look at the sub-limits, which define the limit up to which the insurer will cover medical expenses and the co-pay one has opted in the health plan.

“These are to be paid by the insured. If the insured opts for a room rent higher than that defined in their policy contract then the difference is to be paid by the insured as well,” Nerurkar added.

Hospital room charges and consumables

Generally, health insurance policies have pre-defined hospital room rent up to 1% of the sum insured. But if you get admitted to a room with higher charges than prescribed in the policy, you will have to face major deductions as various expense heads like doctor charges, investigation charges and OT charges depend on the room the patient is admitted in.

Most policies do not cover the cost of most consumables used to treat diseases in a hospital. According to Nerurkar, policy contracts are priced taking into account the treatment costs, “Some other expenses which differ from one facility to another and are not standardized are not covered under health insurance policies. The major headings can be administrative charges, housekeeping items, part of room charges, disposable surgery items, etc.,” he explained.

Co-payment clause

Most health insurance providers offer services with a ‘copay clause’. Many new policyholders are simply unaware of the concept. The co-pay clause basically indicates a percentage of the claim amount that is borne by the insured person. The remaining amount will be paid by the insurance company.

It is an admissible claim amount that both the insurer and insured share on a percentage basis. The co-pay clause, along with the percentage, is mentioned in the policy document and applies to medical services.

Therefore, the bottom line is to read the policy document very clearly and clarify doubts, if any, with your insurer well before time to avoid any chaos at the time of a claim settlement.