Don’t expect your health insurance to pay full medical expenses!

Many people complain that the insurance companies have cheated them with regard to the payments made under mediclaim. Upon asking for explanation, we find out that the issue they are pointing out is that the settled amount is far less than the actual bill amount. Most people are under the impression that mediclaims pay the full hospitalisation charges. However in reality, it is not. There are many items that are not payable and there are lots of restrictions linked to the sum insured. The saddest part is that all these payment restrictions and deductibles are clearly mentioned in the policy wordings that the insurance companies attach to your policy document.

Room restrictions: Most regular mediclaims have a restriction on the ‘per day’ room rent that is payable. It is often stated as a percentage of the sum insured chosen e.g. 1% of the sum insured chosen. The logic behind this is that in hospitals the cost is treatment is linked to the type of room you are staying in. Higher the room rent, higher would be the allied costs. If you stay in a room that cost more than the specified percentage, all other costs would be restricted to the specified percentage and the balance amount will have to be paid by the policyholder. In the final bill there would be limit for the maximum room rent charges for any one hospitalisation. For e.g, if the sum insured is Rs.1lakh, then in the final bill room rent component cannot be more than 25% of sum insured or in other words, rent would not be paid beyond Rs. 25000/-

Co-pay: In some policies, especially senior citizen’s policies, there might be an element of co-pay which means that out of your claims a said percentage would have to be borne by the policyholder. For example, in Senior Citizen’s policy there is a10% co-pay for each and every claim. In other words, for every Rs.100/- payable under the policy, the insurance company would pay you only Rs.90/-.

Per Illness restrictions: In certain policies, there are disease wise limits on the amount payable. Disease like cataract, hysterectomy and so on would have restrictions mentioned in the policy. These restrictions are kept in order to make sure that the hospitals do not overcharge patients for certain regular procedures, just because they hold an insurance cover.

Apart from the major non-payable or restrictive headings there are lots of expenses that mediclaims don’t cover. Registration charges, cost of spectacles, hearing aids, cost of items that can be further used at home like crutches and wheelchair, cost of disposable items and so on are so of the expenses that will not be covered under mediclaim.

In order to avoid such shocks and to make arrangements for non payable items, it is recommended that you read your policy wording clearly before you plan to claim under it. In case you require any clarification on any of the clauses stated, contact your insurance broker.