Handy Tips on How to Lodge a Health Insurance Complaint!

Whenever there is any occurrence of any unexpected health hazard, a health insurance plan has turned out to be a genuine privilege mostly. The prime intent behind buying a comprehensive health insurance policy is that it will take care of the medical-related expenses such as the pre and post hospitalization, diagnostic, medicines, ambulance and various other expenses.

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    The health insurance policy acts as the shield to your savings bank account in case of any medical-related emergencies during the policy term. There is a common notion wherein people believe that a health plan only covers hospitalization expenses. However, this is not true. The right health insurance plan in India will provide a cover for every incurred medical expense such as the everyday hospital charge, ambulance, medicines, and so forth. You can compare the health insurance quotes online before making the purchasing decision. In case you face a problem in regards to the health insurance claim process, then you have all liberty to file the complaint against the health insurer.

    In this article, we are going to discuss and understand the process of lodging the complaint against the health insurance claim.

    Types of Insurance Frauds!

    In recent times, health insurance has become a fast-growing market. However, the fraud in this segment is also one by representing false fact representation and obtaining the amount for anything else and then claiming it’s the health-related needs.

    These frauds are executed in wider aspects and can be done by the insurer and the insured. In case you do not know, the government also provides the provision of filing this complaint against the health insurer. Let us now understand the common types of prevalent frauds listed below:

    • Opportunity Fraud: Such sort of fraud is shown as the natural occurrence, however, in reality, it is calculated and put forward in the way wherein the claim that one intends to take comes within the terms of the policy. For instance, an accident or a mishap will be shown in an over-taunted manner simply to obtain the insured sum at the earliest.
    • Application Fraud: It is one common fraud category that is mostly witnessed in the health insurance industry. Within this, the policyholder provides false information in regards to the existing illness. It is also possible that the insured may not talk or likely give any sort of information simply to get more time in the policy. The employer might also tamper the date of joining of the employee simply to get the approval of the health insurance claim from the insurer.
    • Eligibility Fraud: In an eligibility fraud, the facts are put up false before the insurer. This false information could be anything such as the salary, existing illness, age, the dependent, and so forth. For instance, a part-time employee who is not eligible for the benefits of a full-time working professional, with the help of the HR person, false records are generated and then the reimbursements are made.
    • Internal/ External Fraud: The frauds that are done by the external factor are said to be the frauds carried by the policyholder, the beneficiary, the medical vendor, and so forth. While the internal frauds are carried by the inside person against the insured, this insider person could be anyone from the company right from an executive to a manager.

    Fraud from Insurer’s End

    Further, let’s discuss what if the insurance provider executes any sort of fraud against the policyholder. Let us understand what the insured needs to do.

    File a Complaint to the IRDAI

    In case you are not content with the insurance provider and have evidence to substantiate that the company is at fault and not you, all you need to do is file a complaint against the health insurance company in the IRDAI.

    As per the directives of IRDAI, for the interest of the policyholders, the companies have been put in for the turnaround times for the services it renders. On the premise of the redressal system of the complaints, there is a fixed turnaround time for all the insurance companies.

    In case the company is not resolving in time from where you got insured within the set TAT by the IRDAI, then you can directly approach the governing authority for instant solution. The IRDAI does not delay the process and will discuss the matter with the company at the earliest. In case of any other inquiry, the insured needs to lodge a formal complaint in the consumer court.

    How to Lodge the Complaint?

    For the redressal of the complaint, you simply cannot reach the IRDAI directly. To begin with, visit the grievance cell of the company, which is located inside a branch. The complaint needs to be in writing and submitted along with all the supporting documents. After this, the company will provide the written cognizance of the complaint with the date of submission. The companies take 15 days to resolve the problem. If it is not addressed then you can request the governing body to address the grievance and likewise provide the solution.

    You can also file the complaint against the health insurance company in IRDAI by dropping an email or get in touch on the helpline number.

    You May Like to Read: How to File a Complaint Against Your Health Insurer

    Look for These Factors & Reduce the Chances of Getting Ditched!

    When it comes to buying the health insurance policy in India, you might have certain doubts. Listed below are some factors that you need to contemplate before you zero down the health plan. By adhering to them you might reduce the chances of getting disappointed by your insurer:

    • Scope: Before you pay the health insurance premium, it is highly recommended to check every aspect of the plan. While buying the plan do not simply look for a low premium sum. Go with the health insurance plan that gives you the maximum coverage at the nominal premium.
    • Size of the Family: Every family is different and the number of family members would also vary. Therefore, you should cross-check with the health insurance company whether or not all the family members are covered within the health plan or not.
    • Claim Settlement: It is highly recommended to check the claim settlement ratio of the health insurance company. In case the number is low then it means that you will have to face trouble in regards to the health insurance claim process in the future. In case you have forgotten to take into consideration this aspect while buying the health plan, you can easily file a complaint against the health insurer if required.
    • Sub-limits: On every insurance policy, there is a point of entry in the form of sub-limits. In case the policy states the same, it implies that the policy will cover most of the expenses. There is a need to understand such factors so that you can extract the complete potential of the policy.
    • Restore Benefit: In case the expenses have been made, possible the plan might offer a facility of restoring the benefits. When buying a plan, make sure that in case there is no option of the restore benefits then ask the health insurer for the cost-effective top-up packages.

    Final Advice!

    When you are exploit with many health insurance options available in the market, the chances of getting mis-leaded is also higher. It is your duty to research thoroughly before buying a plan, especially about the background of the insurer, so that you don’t face any harsh time while claiming the policy.

    Written By: PolicyBazaar - Updated: 29 July 2021

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