Know When the Health Insurance Claim Amount Will Not Be Settled

When it comes to buying a health insurance policy, make sure that you choose a health insurer who has a decent track record of stable claim practices. Once you are convinced with the proven track record, thereafter, go with the fine print of the products, which suit your needs the most.

Read More

Policybazaar exclusive benefits
30 minutes claim support##
(In 120+ cities)
Relationship manager
For every customer
24*7 claims assistance
In 30 mins. guaranteed*
Instant policy issuance
No medical tests~
People trust Policybazaar^
6.7 crore
Registered consumers
Insurance partners
3.4 crore
Policies sold
Policybazaar is one of India's leading digital insurance platform


Find affordable plans with up to 25% Discount**

Select members you want to insure

  • More Members
  • Back
    By clicking on “Continue”, you agree to our Privacy Policy and Terms of use
    Maximum child sum can be 4
    This will help us calculate the premium & discounts for your family
    Previous step
    This will help us to find the network of Cashless Hospitals in your city

      Popular Cities

      Previous step
      Get to plans directly next time you visit us
      Please provide your active international number
      Previous step
      We will find you the plans that cover your condition.

      Do any member(s) have any existing illnesses for which they take regular medication?

      Get updates on WhatsApp

      Previous step

      When did you recover from Covid-19?

      Some plans are available only after a certain time

      Previous step
      Advantages of
      entering a valid number
      You save time, money and effort,
      Our experts will help you choose the right plan in less than 20 minutes & save you upto 80% on your premium
      Advantages of entering an International Number
      Prompt connectivity
      Find the right plan in under 20 minutes
      Get best discounts
      Ensure smooth issuance

      In these tough times of COVID-19, health insurance coverage is surely the need of the hour. When buying the health insurance plan it becomes important to understand various terms and conditions that the plan has to offer or else during the health insurance claim process, the disallowances might give you hicups.

      Knowing the health insurance policy will enable you to avoid a bad experience later. You must be aware of various insurance-related terminologies and the effect it has during the stage of the health insurance claim. Let us understand some of the common reasons for the disallowances listed below:

      Room Rent Restrictions: One of the common mistakes that many of the customers make is that when buying the health insurance policy they do not pay heed to the restriction upon the room rent or the category. On the premise of the sum insured or the chosen hospital, the out of the pocket costs could run high just because of the category restriction/ rent in the policy.

      Most likely the health insurers will limit the rent of the room to one to two per cent of the sum insured; however, the same limit is not applicable when it comes to the admission in the ICU as per the regulations of IRDAI. Let us just assume that in case you have Rs 3 lakh sum insured, where you will be entitled to the room rent of Rs 3,000 that is assuming the 1% limit and if admitted in the room with everyday room rent of Rs 5,000 that is the average rent of the single room in an urban hospital then most likely you would be paying 40% of the bill from your pocket excluding the expense of drugs, implants, consumables, etc.

      It is to be noted that this will be large in a critical scenario wherein the treatment is then taken in tertiary care hospitals. So, do not buy a health insurance plan with the low limit upon the room rent. There are other types of room rent restrictions, which has a slightly less effect on the disallowances. The first sort is equivalent to the 1-2% of the above restrictions and there is no proportionate deduction.

      Now, the health insurer might disallow the difference in the rent of the room. Besides, the insurer would also restrict a room category, which would be chosen such as the semi-private room. In case of a high room category, it would either lead the co-pay or the proportionate deduction. When you choose the category of room, which is permitted in the policy then there is no disallowance on account of the room rent.

      Co-pay: When it comes to co-pay, it is the cost-sharing provision wherein the percentage of a health insurance claim is borne by the insured. The studies depict that the cost-sharing provisions are influenced by the manner the services of health are consumed upon the premise of two reasons primarily.

      The cost-sharing provisions show to control the moral hazard simply by decreasing unnecessary health services consumption.   The customers also tend to sign the unchecked bills in the case when the payment has to be done by the health insurers; however, the same customers will scrutinize the charges in case of the co-pay. Usually, ten per cent co-pay is manageable, however, large co-pay in the policy could also entail huge out of pocket expenses specifically in case of the major claim.

      Let us just assume that you have a 20% co-pay in the policy and a claim of Rs 50,000 is made then the sum of Rs 10,000 will be bear by you and the health insurer would only pay Rs 40,000. In case of a Rs 5 lakh claim then out of the pocket costs could be Rs 1, 00,000.

      Now this is a sum that most of the mediocre families would find it tough to pay. Therefore, check for the level of co-pay in the policy with, which you are comfortable with. It is possible that with some of the policies, the treatment city, the room choice, and so forth would also trigger the co-pay quantum. Therefore, it is better to understand such provisions before you make the buying decision of a health insurance policy.

      • Consumables: Take any average hospital bill, the three to six per cent of the charges are for the consumables such as cotton, dressing, gloves, disposables, and so forth. In the times of COVID-19, these charges have burgeoned up to 15-20 per cent of the bill because of excessive use of the protective gears such as the masks, PPE kits, face shields, gloves, etc. In case the policy does not cover all of these, the customer will have to bear these expenses from their pockets. There are various other reasons for the disallowances that are good to understand, however, entail heavy burden on the customers.
      • Procedure Sub-limits: In certain cases, the policies do have specific limits for the common surgical treatments such as a hernia, cataract, etc. that is much lower than a policy limit. So, when the bill is more compared to the procedure limit, then it would be you who need to bear the difference in the expenses.
      • Policy Sub-limits: The policy could also have sub-limits for certain benefits that are lower than the sum insured. Check the policy for the sum-limits for any benefits specifically, for instance, a Rs 50,000 limit for the AYUSH treatments. In some of the policies, the pre and post-hospitalization costs are capped at 10% of the inpatient claim.

      The Bottom Line

      Regardless of whether you buy offline or online health insurance, make sure that you check the policy wordings, thoroughly read upon the terms and conditions of the policy and get all the doubt clarified. Only, after all this sign below the dotted lines.

      It is advisable to buy online health insurance and compare the quotes and features available in the market. Remember, a little attention to the health insurance details will take you a long way towards a worry-free life.

      Disclaimer: Policybazaar does not endorse, rate or recommend any particular insurer or insurance product offered by an insurer.

      Health insurance Articles

      • Recent Article
      • Popular Articles
      17 Jul 2024

      Does Care Health Insurance Cover Dengue...

      Every year, we look forward to the monsoon to escape the heat, but

      Read more
      16 Jul 2024

      Does ICICI Lombard Health Insurance Cover Dengue...

      As the monsoon season arrives, the risk of vector-borne diseases

      Read more
      15 Jul 2024

      Does Star Health Insurance Cover Dengue...

      In India, the high incidence of vector-borne diseases like dengue

      Read more
      01 Jul 2024

      Surgeries Covered Under ICICI Lombard Health...

      Life can throw unexpected medical emergencies your way, making

      Read more
      27 Jun 2024

      Is LASIK Surgery Covered by ICICI Lombard Health...

      Waking up with a clear vision is a dream for many. LASIK surgery

      Read more

      How to Apply for Ayushman Bharat Pradhan Mantri...

      Ayushman Bharat Yojana is a flagship health insurance scheme launched by the Government of India to offer universal

      Read more

      How Senior Citizens can save Tax with Medical...

      Senior citizens can save on income tax by availing tax benefits on medical expenses under Section 80D of the Income

      Read more

      10 Major Benefits of Ayushman Bharat Yojana

      Pradhan Mantri Jan Arogya Yojana (PM-JAY) is the second component under Ayushman Bharat Scheme. PM Narendra Modi

      Read more

      Best Health Insurance Plans for Senior Citizens

      Senior citizens are the most prone to diseases. Considering the medical inflation in India, buying health insurance

      Read more

      10 New IRDAI Health Insurance Guidelines in 2024

      Health insurance penetration in India is far lower than it should be. A significant chunk of the Indian population

      Read more

      *We will respond in the first instance within 30 minutes of the customers contacting us. 30-minute claim support service is for the purpose of giving reasonable assistance to the policyholder in pursuance of the claim. Settlement of claim (including cashless claim) is the responsibility of the insurer as per policy terms and conditions. The 30-minute claim support is subject to our operations not being impacted by a system failure or force majeure event or for reasons beyond our control. For further details, 24x7 Claims Support Helpline can be reached out at 1800-258-5881. Product information is authentic and solely based on the information received from the Insurer. Policybazaar is acting only as a facilitator and claims settlement shall be at the sole discretion of the Insurer. As per the Insurance guidelines, you are allowed to cancel the policy with-in 15 days from the date of Issuance of policy. For more details, please read the Plan Brochure carefully or talk to our advisor at the time of purchase.

      *All the health insurance plans cover hospitalization expenses including COVID-19 treatment cover up to the specified limits. You can also buy specific COVID-19 health insurance policies such as Corona Kavach Policy and Corona Rakshak policy.

      **All savings and online discounts are provided by insurers as per IRDAI approved insurance plans. #Tax Benefits are subject to changes in tax laws. GST Exemptions depend on fulfilment of qualification criteria and submission of relevant documents.

      *₹1748/month is the starting price for a 1 crore health insurance for an 18-year-old male, with no pre-existing diseases. Discount on renewal premium is subject to the number of wellness points earned in the health insurance policy. For more details about the plans, please read the sale brochure carefully to get upto 100% discount on renewal premium.

      *₹400/month is the starting price for ₹ 5 lakh Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases

      *₹541/month is the starting price for ₹ 10 lakh Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases

      *₹762/month is the starting price for ₹ 1 Crore Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases

      *₹243/month(₹ 8/day) is the starting price for a 5 lakh health insurance for a 20-year-old male, non-smoker, living in Bengaluru with no pre-existing diseases

      *₹2020/month is the starting price for ₹ 1 Cr Health insurance for a 50 year old male & 50 years old female, living in Bangalore with no pre-existing diseases rounded off to nearest 10.

      *₹390/month (₹13 per day) is starting price for 1 cr. Health insurance for 25 years old male, with pre-existing diseases, residing from tier 1 city rounded off to the nearest 10.

      *No medical tests are required unless requested by the insurer’s underwriter. In-case of pre-existing diseases relevant medical proof would be required as per the terms and condition of the policy opted.

      *The values taken for effective cost calculation are indicative values and may change as per the selected plan.

      *Coverage upto double the amount of Sum Insured is available on certain covers for a minimum plan of Rs. 5 Lakh on the first claim only to an individual of upto 45 years of age with no pre-existing diseases. The benefit is available with or without extra cost depending on the plan chosen.

      *Coverage of pre-existing diseases is provided by insurer as per their underwriting policy.

      *The scope of coverage may vary from plan to plan.

      ~Source: Google Review Rating available on:-

      ##On ground claim assistance is available in 114 cities

      Tax Benefits are subject to changes in tax laws. GST Exemption depends on fulfilment of qualification criteria and submission of relevant documents as required by the insurers. For more details on risk factors, terms and conditions, please read the sales brochure and applicable rules and regulation carefully before concluding a sale.

      STANDARD TERMS AND CONDITIONS APPLY. For more details on risk factors, terms and conditions, please read the sales brochure carefully before concluding a sale.

      Policybazaar is a registered Composite Broker |Registration No. 742, Valid till 09/06/2024, License category- Composite Broker (Life & General)| Visitors are hereby informed that their information submitted on the website may be shared with insurers.

      Policybazaar Insurance Brokers Private Limited | CIN: U74999HR2014PTC053454 | Registered Office - Plot No.119, Sector - 44, Gurgaon, Haryana - 122001 Contact Us | Legal and Admin Policies

      © Copyright 2008-2024 All Rights Reserved.

      Download the Policybazaar app
      to manage all your insurance needs.