People buy medical insurance so that they can claim reimbursement of their expenses. However, at times, insurance companies reject their claim requests due to certain exclusions, waiting period and so on.
To make sure that they have a flawless claim experience, here are a few factors that you must definitely talk about while helping people choose health insurance policies
Adequate sum insured
Health insurance policies tend to have sub-limits, that is, the maximum amount that insurers can pay your clients for an expense such as room rent. Typically, sub-limit depends on sum insured. For instance, if a policyholder has bought a health insurance policy having sum insured of Rs.5 lakh, he will only get Rs.5000 per day for hospital room or bed. Therefore, if a policyholder chooses a better room, they have to bear an additional expense.
Another way to look at an insurance policy is through the prism of no-claim bonus. Many policies offer an enhanced sum insured facility if a policyholder does not file a claim as no-claim bonus. This often helps policyholders get enhanced sum insured with the same premium amount.
Deductions in claim amount
Agents must explain key features of a health insurance policy that can cause dissatisfaction at the time of claim settlement such as:
• Proportionate deduction: This applies to policyholder on choosing a room above the category specified
• Waiting period: Most health policies do not cover diseases like cataract, kidney stones for the first two years
• Co-pay: It is a fixed percentage of the total hospitalization expenses that policyholder has to pay
Pre-existing diseases
Often policyholders do not disclose their pre-existing conditions to take advantage of reduced premium rate. However, not disclosing pre-existing conditions or illnesses can lead to adverse consequences. Here is an example:
A policyholder gets treated for a stroke. After he gets a discharge, he files a reimbursement claim. But the insurance company rejects his claim. Why? On evaluation, the insurance company finds that the policyholder has a history of diabetes, which was the reason he/she got a stroke.
As a policy advisor, it is your responsibility to advise your client on the significance of disclosing pre-existing conditions.
Porting
Porting means transferring from an old policy to a new one. While the policy benefits remain the same, time-bound exclusions are transferred. If you find your client looking for better coverage, porting is the best option you can suggest to them because it will help them increase the coverage without losing the coverage of their previous policy. Here is an example:
A policyholder has completed 2 years of a policy with 3 years of waiting period on a pre-existing condition. If he/she chooses to port the policy with the same waiting periods then only a 1-year waiting period will be applied if porting is done on time. Moreover, the 30-day waiting period after buying a policy will not be applied.
The job of a policy advisor is not limited to the sales. Instead, you should ensure that your clients have a great experience throughout the policy term.
Anuj Jindal is a co-founder of SureClaim, a claim settlement consultancy firm. The views expressed in this article are solely of the author and do not reflect the views of Cafemutual.
