According to reports from Mint, having an active health insurance policy and paying premiums on time does not guarantee that every hospitalisation will result in a claim payout. Insurers assess claims against the policy's terms and conditions, including waiting periods, exclusions, medical necessity and documentation requirements. Non-disclosure of medical history, claims made during waiting periods and inadequate medical records are among the reasons an otherwise active policy may not result in a payout. Experts note that policyholders often discover these conditions only when they need to use their insurance.
As reported by Mint, non-disclosure or incorrect disclosure of medical history is one of the key reasons for claim disputes. According to Bikash Choudhary, CEO of FatakSecure, a condition that was not mentioned while buying the policy can later appear in hospital records when the policyholder is admitted for treatment. Choudhary emphasized that policyholders should not assume that a condition mentioned informally to a doctor but omitted from the insurance proposal form is irrelevant. Waiting periods can also apply to specified illnesses and procedures, with Vineet Gupta from ManipalCigna Health Insurance citing kidney stones as an example of a condition that may be covered only after the applicable specified-illness waiting period.
According to Mint reports, every health insurance policy has exclusions, and a claim can be rejected when the treatment or circumstances fall within one of them. Gupta from ManipalCigna Health Insurance noted examples include cosmetic procedures, except where reconstruction is medically necessary in circumstances such as an accident, burns or cancer. Outpatient treatment is another area where consumers can have incorrect expectations, with routine doctor consultations, diagnostic tests or medicines purchased from a chemist may not be covered unless the policy specifically provides OPD coverage. Claims can be rejected if the treatment does not meet the policy's definition of medical necessity or if the need for hospitalisation cannot be established.
As reported by Mint, documentation can also determine whether a claim is processed, with claims facing rejection where medical records are insufficient, incorrect or unavailable for verification. Shashi Kant Dahuja from Shriram General Insurance advised policyholders to preserve their medical records and claim-related documents, including prescriptions, investigation reports, discharge summaries and hospital bills. A denied cashless request does not necessarily mean the treatment itself is excluded from the policy. Gupta explained that if a cashless request is declined, the policyholder can pay the hospital and subsequently submit a reimbursement claim, which will then be assessed under the policy's terms.
According to Mint reports, experts recommend consumers should not select a health policy based only on the premium and sum insured. Gupta recommends reading the policy's inclusions and exclusions, waiting periods, room-rent conditions, co-payment clauses and geographical scope before purchasing it. Dahuja advised consumers to understand deductibles, disease-specific restrictions, pre- and post-hospitalisation coverage and network-hospital conditions. Choudhary recommends starting with the Customer Information Sheet, which summarises key policy terms, and then checking definitions, waiting periods, exclusions, payment conditions and non-payable items. The key point for policyholders is simple - an active health insurance policy means the cover is in force, but the claim still has to satisfy the policy's conditions.
