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‘Mediclaim rejected. Please help’

Rakesh Kaul, CDO, Edelweiss General Insurance, answers your health insurance queries.

Nida Shaikh: Recently after being hospitalised and treated for jaundice, my health insurance claim was declined and the insurer said that this was due to co-payment conditions. Can you please explain what this means? What should I do now?

Rakesh Kaul: Co-payment means a cost sharing requirement under a Health Insurance Policy. It means that the Policyholder/Insured will bear a specified percentage of the admissible claims amount. A co-payment does not reduce the Sum Insured.

Co-payment can, however, be defined or interpreted differently, hence to advise further on this case, more details of claim and coverage will be required.

Manoj Dhama: Recently my father had a cardiac arrest and he was hospitalised. The treatment is over now; however, the health insurance company rejected his claim saying that the hospital’s documentation was not in order. Nobody is helping me file my father’s claim and the hospital authorities are blaming the insurance company. What should I do?

Rakesh Kaul: If the treatment is taken on a cashless basis, the decision will be real time. Minimum requirements for claim adjudication are discharge summary and the final bill.

In case any pre-existing condition is mentioned in the documents, the insurance company might ask for further clarifications on duration of the ailment, etc. as the reason for hospitalisation might be related to insured having a pre-existing condition. However, if any such condition is already disclosed by the insured, then the claim can be processed further, subject to policy terms and conditions.

Biswajeet Gurtu: My wife has been diagnosed with zero stage cancer and she was hospitalised for 2 weeks. Her health insurance covers critical illnesses. Would she be able to claim insurance?

Rakesh Kaul: Yes, claim is admissible under critical illness subject to waiting period and other policy terms and conditions

Vina Vin: I wish to buy Mediclaim Insurance Policy for my 30-yr-old medico daughter who is working in a hospital. She is asthmatic & had been AVN operated. Can she have a policy? If yes, then which is the appropriate one to be taken and which company offers the best one.

Rakesh Kaul: As per the details of disease shared, policy can be offered to the customer as per the Insurance companies Underwriting guidelines, current health status and subject to the medical check-up findings. Would advise you to compare the policy benefits and other criteria and accordingly choose the policy that best suits your requirement.

Janak Raj: Sir/Madam, I have an elder sister, 46, with two children and husband. She is not good in good financial condition and I am also single earning hand. So I want to take a health insurance policy for her, with minimum premium and with minimum sum assured. Please help me by suggesting the best health insurance policy for her.

Rakesh Kaul: There is a basic health insurance product with standard terms & conditions named Arogya Sanjeevani. This was initiated by IRDAI and is being offered by various insurance companies. You can compare the premium, policy benefits, etc. to choose a policy as per your needs.

Venkatraman Pitchai: Is it advisable to buy a fresh a mediclaim policy at the age 66 from Star Health Insurance for Rs 5 lakh at annual premium of say approx. Rs 21,240? At present I have National Insurance Mediclaim Policy for Rs 5 lakh but unfortunately they jacked up the premium for renewal at Rs 56,285 which I cannot afford at this juncture as I am retired and having NO income. My savings like FD etc. are also meagre. Kindly advise so that I can buy suitable mediclaim policy for me.

Rakesh Kaul: Buying a fresh health insurance policy will lead to loss of the existing health policy continuity benefits and Cumulative bonus. Would suggest you explore the policy portability option to retain the continuity benefits and choose the desired sum insured and corresponding premium suitable to your needs.

Mahaveer Parakh: I am a senior citizen, 75, with no life-long disease, viz., BP, sugar, etc. My wife, 72, has diabetes, BP and osteoporosis. Kindly suggest which mediclaim policy to be taken for both of us. Please note, I am a middle class person retired long back.

Rakesh Kaul: I would advise you to look at policies which are specifically designed for senior citizens. These are available at an affordable premium considering the retirement status and elderly age of an individual.

Maqsood Ahmed: I have the following members in my family. Please suggest the best insurance policy for me which will cover my family members and me.

Myself: 55 years — Diabetic on tablets

Wife: 48 years — diabetic on tablets

Daughter: 24 years

Daughter: 20 years

Son: 16 years

Rakesh Kaul: There are various insurance companies offering health insurance policies for pre-existing health conditions. You can compare the coverage, pre-policy medical check-up criteria, premium, sum insured, claim payment ratio, claim service and accordingly select the best policy.

Do you have health insurance queries? Please mail us at [email protected] with the subject line ‘Ask Rakesh’ and Rakesh Kaul will answer your health and auto insurance queries.

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