The IRDA is the sole governing institute for all insurance bodies in India. An average consumer puts in a lot of effort into assessing the claim settlement ratios of individual insurance companies before they buy their product.
Understanding past claims and track record of settlements of an insurance company is important while shopping for a medical claim insurance. While this may be an essential parameter to judge the institution, it’s certainly not everything. Read on to know more.
Claim Settlement Ratio in Health Insurance
Claim Settlement Ratio in health insurance is the ratio of claims submitted to claims settled in a given time. The proportion of claims filed against the number of claims paid or settled is measured. When all submitted claims are paid, the company can claim 100% settlement ratio. Subsequently, when there are rejected claims – the ratio is below 100%.
Why do Health Insurance Claims get rejected?
Health insurance claims are mainly rejected due to the following:
- Pre-listed conditions within the contract:
To keep the plans viable and make premiums affordable, the insurance provider lists certain conditions like waiting periods, sub-limits and exclusions. Therefore, claims that fall into these categories are exempted. These are approved by IRDA.
- Fraudulent and misrepresented claims:
Falsified records or undisclosed information if traced, can lead to claim denial. This is usually the case where petitioners sign their forms without thorough study.
Outrageous charges quoted by the treating doctor or the hospital, fraudulent claims by a group of patients, etc. are also not entertained.
An efficient health insurance company that has proper legalities in place is due to see rejections. This proves that claims settled and rejected are both in accordance with the contract, without deviations.
How to Ensure 100% Claim Settlement
Here are some key parameters to make sure your claim is not rejected:
- Always fill the contract yourself and read the proposal document thoroughly before signing.
- Take the time to analyse terms and conditions of the policies. Use web services and online comparison tools to find your perfect health insurance plan
- Private analyses indicate that about 95% of health insurance claims are rejected. Ensure that all past and present health conditions are truthful
- Make sure declarations of the dependants like parents and in-laws, spouse and children are updated.
- File claims within the time frame in the contract.
- Provide all the necessary details requested by your insurer. Speak to your broking firm or an agent for clear understanding.
What to do when your Claim is rejected?
The following is the route to take when filing a grievance:
- Go back to the contract and check for inaccuracies and misinterpretation of information.
- Contact TPA to rule out systemic errors or communication problems.
- Check supportive documents submitted for the medical insurance being claimed. Ensure all reports, bills including pharmacy receipts are there.
- Talk to your doctor or hospital about providing adequate proof if your claim is denied for unnecessary medical procedure.
- Register an appeal with the insurance company first, stating all the reasons and with all the proofs.
If your insurance company further rejects your claim or if there is no response within 30 days of filing, you can register a complaint with the insurance Ombudsman, who will then follow legalities to test your claim and offer a solution.
Top Five Health Insurances for 2015-16
- Apollo Munich: 89%
- Religare: 87%
- Star Health: 79%
- Max Bupa: 86%
- Cigna TTK: 94%
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Claim Settlement Ratio
100% Claim Settlement
What to do when your Claim is rejected