Key Factors To Remember For Elderly Parents’ Health Insurance Claims
One day, while returning from the office, you receive a call from home informing you that your father is experiencing sharp chest pain. Panic strikes, and you rush him to the hospital, relieved that a health insurance policy covers your family. However, after getting your father admitted, you start wondering about the process of raising a claim, whether any clauses could affect claim approval, and what conditions insurers do not cover. We will discuss all of this in this article.
Key considerations before making a claim for senior citizen health insurance
Here are significant factors you must consider before filing a senior citizen health insurance claim:
1. Waiting period
A waiting period in a health insurance plan for a family refers to a time during which policyholders cannot claim benefits for specific conditions. Depending on the condition, this period can range from 30 days to 3 years. Before proceeding with a claim, you need to read the waiting period clause to ensure that the condition for which you are admitting your parents to the hospital has surpassed this period.
2. Deductibles
A deductible in health insurance is the amount policyholders must pay out of pocket before the insurance company begins covering medical expenses. This arrangement can lower premiums but increases initial treatment costs. For example, if your elderly parents’ health plan includes a ₹20,000 deductible and hospitalisation expenses total ₹35,000, the insurer is only responsible for ₹15,000. However, if the bill amounts to ₹18,000, then the full payment obligation falls on your parents' shoulders.
3. Co-pay
Co-pay in health insurance is a fixed percentage that policyholders must pay for medical expenses, while the insurer covers the remaining amount. For example, if a senior citizen health insurance plan has a 20% co-pay clause, it means that regardless of the treatment cost, you are responsible for 20% of the amount, while the insurer will cover the remaining 80%.
4. Restoration clause
Senior citizens often require frequent hospitalisation, and there is a high chance of completely exhausting the base sum insured. In such scenarios, checking whether the insurer offers a sum restoration benefit is important. If so, determine whether the restored amount can be used for the same illnesses for which claims have previously been made or only for other conditions.
5. Conditions for which you cannot make a claim
Not all medical conditions are covered by the insurer. Before making a claim, it is advisable to review the policy brochure to understand what is excluded from coverage. Here are some insights into the exclusions:
Coverage will not be provided if your parents require dental treatment that is not the result of an accident.
The insurer will not cover the cost of dietary supplements. For instance, if your parents take expensive protein powder to stay active, they must pay for it themselves.
Any surgery related to weight management or obesity is not covered.
If your elderly parents have a habit of excessive alcohol or drug consumption, no coverage will be provided.
Injuries sustained due to a suicide attempt are not covered.
The insurer does not cover treatment related to AIDS or certain permanent diseases.
How to raise a health insurance claim for senior citizen parents?
The insurer allows you to file either a cashless or a reimbursement claim. Here are the steps involved:
Cashless claim
Navigate to the insurer's official website and locate the nearest network hospital by entering your state and city name. Alternatively, you can contact the insurer’s customer support for assistance.
Inform your insurer or the third-party administrator about the reason for your parent’s hospital admission. If the treatment is pre-planned, it is advisable to notify them 3-4 days in advance.
Complete the pre-authorisation form available in the hospital’s insurance section or download it from the insurer’s website.
At the TPA (Third Party Administrator) counter, fill out the completed form and attach all relevant prescriptions, medical reports, and your parent’s ID proof.
The insurer will review your application and documents, and if everything is in order, they will process the claim. The bills will be cleared directly with the hospital. However, you must pay the deductible amount specified in your policy before settlement.
Reimbursement claim
Inform your insurer about the treatment within the specified timeframe.
Collect all the necessary documents like medical reports, a discharge summary, hospital bills, and pharmacy bills.
Download the claim form from the insurer’s website, fill it out, and submit it along with the necessary documents.
The insurer will review the documents, cross-verify them with the hospital, and release the claim amount, which will be credited to your chosen bank account in the next few business days.
Conclusion
In conclusion, claiming health insurance for your elderly parents requires careful attention to detail. Always check your policy's waiting period, deductibles, and co-pay percentages. Understand the exclusions to avoid surprises, and consider whether your insurer offers a restoration clause for exhausted sums. When filing a claim, follow the correct procedure, whether cashless or reimbursement, to ensure a smooth experience.
Disclaimer: This article is published in association with ICICI Lombard and not created by TNM Editorial.