Health Insurance

If you have an issue with the Health Insurance, you could be entitled to a refund. Use our free tool to raise an issue with the service provider.

Health Insurance is an insurance policy that guarantees that you get cashless treatment or cost repayment, in the event that you become sick. A medical coverage policy reimburses the insured for medical and surgical expenses emerging from an illness or injury that prompts to hospitalization.

Individual medical expenses are sky-rocketing, so get health insurance policies for your medical outlay. With cashless facility, you can stay tension-free. 

 

How will Resolver help you?

If you have a complaint, first make sure that is reasonable. If you believe that it is, you can use Resolver to submit your issue. Any complaint from Resolver is an official complaint, and the provider is therefore obliged to act upon it. Resolver plays the role of the bridge between you and the company you’re complaining to, making it easier for you to get your complaint to the right place at the right time. Resolver is free. No adverts, no hidden costs. Start by telling us the name of the company or organization you have an issue with, raise a case and leave feedback afterwards.

 

What all is included in the health insurance plan?

The coverage offered by a health insurance policy is subject to the type of policy and the insurance provider. An ideal policy is customizable and suits your requirements in the best way possible. Following are some common health insurance policy inclusions:

  1. In-patient hospitalization expenses
  2. Donor expenses, in case of organ transplantation
  3. During injuries requiring overnight hospitalization
  4. Pre-existing illnesses or diseases
  5. Pre and post hospitalization
  6. Ambulance charges
  7. Maternity or newborn
  8. Health  
  9. Daycare procedures
  10. Treatment availed at home or domiciliary hospitalization

 

Things I should know that are excluded from health insurance plan

Coverage offered by health insurance policies varies with the insurer; however, certain points are not covered by health policies and fall under the category of policy exclusions. Following are common health insurance policy exclusions:

  1. If it is an accident, the coverage will be offered, otherwise, it usually takes 30 days for reimbursement
  2. Coverage of critical illnesses and pre-existing diseases is subject to a waiting period of 2 to 4 years.
  3. Maternity/newborn expenses unless a maternity option has been added on.
  4. Injuries caused by war/terrorism/ nuclear activity/suicide attempt.
  5. Terminal illnesses, AIDS, and other similar diseases.
  6. Cosmetic/plastic surgery, hormones replacement, sex change and more.
  7. Dental or eye surgery.
  8. Non-allopathic diseases' treatment
  9. Bed rest/hospitalization and rehabilitation, common illnesses etc.
  10. Treatment/diagnostic tests, post-care procedures.
  11. Treatment abroad or by an under-qualified medical professional.

 

How to claim Health Insurance?

One can plea a claim against an event that is covered by the insurance policy. Following are two claim processes:

  1. Expense Reimbursement: You can get your medical expenses reimbursed by the insurer, based on the policy terms documented. Bed charges, medicines, lab tests, surgeon‘s fees etc. are paid back to the insured at the time of claim. You have to pay the (hospital) expenses but it will get reimbursed by the insurance company later.
  2. Cashless Treatment: Insurance companies provide you with a wide network of hospitals to get medical treatment without having to make upfront payments. No payment is required to be done by the insured, since the clause involves a mutual agreement between both the parties, i.e. the insurer and hospital. In contrast, availing cashless benefit requires TPA approval. The insured can also show the insurer-issued health card at the particular hospital as proof of medical insurance cover along with a valid government ID.

 

How to address an issue with Health insurance provider?

Before lodging a complaint with the health insurance provider, you have to approach the Grievance Redressal Officer of the branch. You have to file the complaint in writing with associated documentation. A written affirmation will be given to you alongside the date of submission of the complaint. Generally, the insurance provider has to resolve the issue within 15 days. In case this does not happen, the issue can be escalated to the IRDA (Insurance Regulatory & Development Authority).



How to file a complaint with IRDAI?

To lodge a complaint with a health insurance provider with the IRDA, the policyholder has to get in touch with the Grievance Redressal Cell of the Consumer Affairs Department of IRDA via email or customer care helpline. You can use the Grievance Management System offered by the IRDA to monitor your complaint and its progress. You can also contact the Insurance Regulatory and Development Authority (IRDAI) via letter or fax.

 

What happens when you purchase an insurance policy/product from a bank?

  • Reserve Bank of India has taken steps to safeguard the rights of customers, in case of third party products like insurance, mutual funds from the bank. 
  • You can file a complaint to the concerned bank’s grievance redressal cell, both offline or online with the detailed facts and circumstances of your case, the relief sought and carry necessary documents and proofs along with your complaint. For a hassle-free, quick process, you can easily file a complaint with your bank via resolver. You are supposed to wait for 30 days. 
  • If the bank hasn't replied to your complaint or you are not satisfied with the response, you can escalate your issue via resolver to banking ombudsman created by RBI to resolve banking issues.

Will I get covered for my pre-existing illnesses?

Each insurance plan avoids inclusion of the pre-existing ailments for a certain time period at the beginning of the policy. You have to discover what this waiting period for your prior sickness is and how soon would you be able to be secured for your previous diseases. Fundamentally, you have to comprehend whether your previous condition is temporarily not secured or is it totally prohibited from the extent of inclusion from the policy.

 

What to do if I am admitted to a non-network hospital?

In a crisis circumstance, you may be admitted to a non-network emergency hospital. You should know that treatment in a non-network emergency clinic would be on a reimbursement basis just where you would need to present the hospital expenses and afterwards get them repaid from your guarantor. For the repayment procedure, keep every one of the documents required for this situation, and check the due date for advising the insurance agency for this circumstance.

Can I transfer my policy from one insurance company to another without losing any renewal benefits?

The Insurance Regulatory and Development Authority (IRDA) has guided the insurance agencies to permit transfer from one insurance agency then onto the next and starting with one policy plan then onto the next, without losing the renewal credits for pre-existing conditions, delighted in the previous policy.

 

How many claims are allowed in a year?

It depends on the policy period unless there is a specific cap prescribed in any policy. However, the sum insured is the maximum limit one can claim under the policy. 

 

Can I extend my health insurance policy to cover my parents/siblings/children?

You can extend your health insurance policy coverage to your dependents like parents, children or siblings. Before you agree to add your dependents to a health insurance plan, calculate the overall insurance cost. If they appear to have a serious illness, premium rates might increase for your current insurance plan. 

In order to add your family to the insurance plan, you have to convince the provider that your parents and siblings are reliant on you for financial and social support.

 

Tips before you renew your health insurance policy

Survey the Renewal terms: Policyholders will be sent a restoration update by the insurance agency 45 days preceding the renewal date. The update will contain policy details, for example, the total amount guaranteed, number and sorts of claims made, and no-claim bonus. Policyholders must be persistent and if there is an error in the policy details, inform the provider immediately.

Prior to recharging, look at different alternatives: Porting a policy from your existing insurer to another would be a safety net for you when you are disappointed with the current insurer either because of higher premium expenses or lower benefits. You won't miss out on the policy benefits, for example, waiting up period and No-Claim Bonus when transporting the policy from one insurer to another.

Disclose new illnesses at the time of renewal: Be honest with the medical details furnished at the time of policy purchase and renewal to avoid any hassle when a claim has to be made in future. 

 

Know your rights once you have taken a health insurance 

 

  • Cancel an insurance policy within 15 days from the date of receipt of the policy document, if you disagree to any of the terms or conditions in the policy.
  • You can
    • Return the policy by stating the reasons for the objection.
    • You will be qualified for a refund on the premium paid. 
    • Any costs brought about by the insurer to attempt the maintenance of your policy will be deducted. 
    • If there should arise an occurrence of unit-linked insurance policy(ULIP) likewise, the insurer can repurchase the units at the cost on the cancellation date.

 

My insurance policy documents are destroyed/stolen, what to do?

You have to file an application before the insurer for the issuance of a duplicate insurance policy document. The insurer will charge you a nominal fee to issue duplicate policy documents. 

  • A written application must be submitted to the insurer, intimating the loss of the policy. The reason for the loss, likely date of loss, policy details, such as policy number, cover, date of issuance, and whether or not the policy was assigned, need to be provided in the application. 
  • If there should arise an occurrence of misfortune/loss, a few insurance providers will demand you place a commercial, at your own cost, in a newspaper in the state where the loss is accounted for to have happened. This must be sent to the insurance agency a month after its appearance. 
  • Certain insurance agencies require the insured to give a indemnity bond on a fitting stamp paper. The document goes for reimbursing the insurance agency for any misfortune that might be caused because of abuse or extortion through the original policy document, and the insured consents to return it, whenever found, to the insurance agency.

 

You recently had a medical procedure but insurer won't pay for it

  • Check your Policy and Paperwork - Look over the outline of benefits in your insurance documents. The paperwork must spell out what's covered. It likewise needs to list the limitations or rejections, which are things your insurance policy won't cover. 
  • Call your insurance agency in the event that you don't have a clue why your case was denied or in the event that you have different inquiries concerning it. You can heighten your issue with the senior administration by means of Resolver to know the essence of your issue.
  • If your insurance company refuses to pay the claim, reserve an option to file an appeal. You can easily forward your issue to IRDA via resolver to get appropriate resolution. 



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