Top 5 Reasons for Health Insurance Deductions

Did you face a deduction in your health insurance claim amount? Don’t worry, you are not the only one who is facing health insurance deductibles.

Deductions or deductibles in health insurance is one of the technical terms used in the insurance industry. To understand why there is a deduction in your claim, you need to first understand what is a claim deduction in health insurance.

What Does Health Insurance Deduction Mean?

Health insurance deduction is the amount that the insurance company deducts from the insurance claim due to certain reasons. As a result, the policyholder is bound to pay the amount (equal to the deduction) for his medical bills out of his pocket.

5 Reasons for Claim deduction in Health Insurance

Co-pay

When the insured agrees to co-payments, then he is bound to pay a part of a claim in some medical situations, and the rest is paid by the insurer. For example, at the time of policy purchase, the insured agrees to pay 40% of the future medical bills, then the insurer will only be liable to pay 60% of the claim amount. The remaining will be borne by the insured. For instance, if the insured gets hospitalized and the total expense came to be Rs 1.20 lakh and as per the insurance company, the claimable amount is Rs. 1 lakh then the insurance company will pay Rs 60000 only (60% of Rs. 1 lakh) and rest other expenses will be borne by the policyholder.

Limit on room rent

If there is a capping on the hospital room rent, then the insurer will only bear the cost of room rent up to the pre-defined limit. If the cost of room rent is more than the limit set, then the additional amount will be borne by the insured.

Poor documentation

If the insured submits incomplete documents of the medical procedure or hospital bills to the insurer, then it would be difficult for the insurer to ascertain the correct and complete claim amount. If Insurer feels that Hospital has not followed standard protocol, then the claim will not be paid.

Procedures not covered

When a particular medical procedure(s) is not covered in the health insurance policy, then the company will reimburse only for those procedures which are covered in the policy.

Unreasonably high charges

If the hospital charges higher charges than needed, then the company will settle the claim according to the pre-defined rates.

If you feel that your claim was genuine and the deduction was not required, then you can contact your insurance company for a short settlement of the claim. If you need help, you can approach Insurance Samadhan.*

Here are Some of the Cases of Short Settlement that Insurance Samadhan Has Resolved:

Case 1

Ria, a health insurance policyholder was diagnosed with Right Renal Carcinoma and a Large Fibroid Uterus. She was admitted to a hospital and underwent Hysterectomy and right Nephrectomy surgeries. Her family submitted a filled claim form along with the necessary documents to the insurance company for reimbursement.

She paid Rs. 20 lakh for the treatment out of her pocket and waited for a reimbursement. The company short-settled the claim by paying Rs. 7 lakh only.

She was shocked by the deductions in the claim settlement as she has paid premium on a regular basis and her sum insured was much higher than the claim amount. She also had no claim bonus for claim-free years. She wanted to raise the question- why was she not fully reimbursed? But did not know how to approach her insurer.

She came to know about Insurance Samadhan and gave us her case. We studies her case and came to the conclusion that it was a genuine case and the client must get her full claim. We guided her in the case. It took 3 months to resolve the case.

Case 2

Jeet was upset as his wife’s health claim was short-settled. Her wife was admitted to the hospital for the treatment of Umbilical Hernia. Jeet notified the TPA by submitting the claim form along with important documents. The couple paid the hospital bills by themselves and patiently waited for the reimbursement.

However, the claim was short-settled. Jeet contacted us with his wife’s case. We studied the case and found that TPA mistook the hospital as a network hospital of GIPSA and processed his wife’s claim accordingly. We informed the couple about the misunderstanding and guided them on how to convey the confusion to the TPA. The case was resolved within 20 days.

Case 3

Sakshi’s (another client) IVF claim was short-settled under the clause of pre and post hospitalisation boundary. She was dissatisfied with the claim settlement. She approached Insurance Samadhan with her case. After studying her policy document, we found that the pre and post hospitalisation boundary was not applicable in her case and there was no capping for the IVF procedure. We helped her with the case and her IVF claim was fully settled.

If your genuine claim gets short-settled or there were some unnecessary deductions in the claim amount, then you can reapply for the claim. If you need guidance in your case, you can contact Insurance Samadhan.

We have resolved 14,500+ insurance-related complaints. These insurance complaints include claim rejection, delay in claim settlement, mis-selling and fraud in insurance.

Contact us to get samadhan for your insurance-related issues, we’ll be happy to help you.

*Insurance Samadhan is a private organization and has no association with IRDA or any Government body.

Click on the below links to read some cases resolved by Insurance Samadhan:

Dengue claim rejection

Mis-selling in a life insurance policy

Cancer insurance claim rejection