2/ Health Insurance cos won't pay based on fixed package charges, unless they are part of a pre-agreed contract.
Insurers will demand a detailed breakup of the package charges and then evaluate the claim against the insurance policy.
3/ Here's how Insurers will look at the breakup from Max
#1 Room Rent, #2 RMO Visits, #3 Nursing, are considered part of Room Chg. If these are billed separately, only Room Rent will be paid.
Consumables under # 7a & # 7b are not covered
Rest of the items are payable separately
4/
- Any ad hoc miscellaneous charge in the breakup are not payable.
- Any charge that is not reasonable (disproportionately high) will be paid only at reasonable rates.
Unfortunately, you pay what is not payable.
5/ Of course, if you have a health insurance policy with a room rent limit, you are up for proportionate deductions.
Which means that if your ICU room limit is 10K per day & you are charged say 20K per day - your entire bill may have a proportionate deduction of around 40-50%
6/ How can you prepare for long term, instead of panic?
a) Have a policy that covers each family member for 10-15L. Ideally 20L.
b) Ensure your policy has no room rent cap.
c) Get a fixed cash benefit policy for the deductions. Read about it here:
Patient hospitalized for 6 days
Insurer pays for 2 days - says no "active treatment" after 2nd day.
Doctor shares logic for the 6-day treatment.
Insurer still disagrees.
Should patients consult insurers before taking medical decisions?
Why do patients suffer for lack of medical regulations?
First, let's understand why this happens.
So, health insurance as per the contract will pay only in case when the hospitalization is
a) "Necessary" and
b) " requires active treatment"
Ok - so what is "Necessary" treatment?
It is when patient can only be treated at a hospital and not at home or in OPD.
For instance, say I meet with an accident, and break my hand.
Now, the doctor needs to apply plaster on my hand.
But say the doctor asks me to get hospitalized for a day - This won't be covered under health insurance.
"What if I skip Health Insurance and build a fund to cover my family’s healthcare."
Fine print + claim hassles have forced all of us to think in this line.
Before you go down that road, here’s a thread on what you need to know
👇🏻👇🏻
Health insurance, despite its flaws, offers some powerful benefits that you should understand before taking such calls.
Let’s break down these powerful benefits of health insurance:
⦿ Lifetime Hospitalization Cover
Once you clear the initial waiting periods, health insurance can practically cover all your hospitalization costs for a lifetime — yours and your family’s.
Regulation does not allow insurers to stop coverage, unless they prove a fraud.
Most of the changes are applicable from immediate effect - unless there is a specific target date mentioned for the change.
Thread time 👇🏻
INCLUSIVENESS:
IRDAI has asked insurers to make available products for 1. All age groups 2. People with medical conditions, including chronic. 3. All types of treatment - including OPD!! 4. All occupations, regions, categories.
All kinds of hospitals including affordable ones.
No denial of coverage in case of emergency situations.