🚨Health Insurance Claims Stories-Hospitalisation not necessary!

Sum Insured=10L
Claim Amount=2.48L

The insurer rejected the claim,
"Saying Hospitalisation was not needed",
The policyholder dragged the insurer to the ombudsman,
Imbodsman instantly ruled in the policyholders' favour

What did he do to win the claim?
Let's find out in this very important claims stories👇 Background to the case:-

Rajesh had a 21-month-old health insurance policy from an Insurer for the Sum Insured of ₹ 10 lakhs with good comprehensive features.

Rajesh had returned from a domestic trip and fell ill with a fever

🚨Room Rent limit and Associated deductions

Policy Amount=25L
Claim Amount-90,000
Room Taken=Deluxe room
Policy Conditions=No room rent limit

The insurer hesitated in paying the claim!🤯🤯

Is no room rent limit a myth or do insurers really offer no room rent limit?
What is the dark reality of room rent limits across insurers?🤔🤔

A thread🧵on if no room rent limit is a reality or not?👇 What is a room rent limit in a health insurance policy?

The room rent limit in health insurance is the maximum amount that an insurance company will pay for a policyholder's hospital room per day

🚨Health Insurance Claims Stories is back

Sum Insured=10L
Claim Amount=Rs 24,497

The insurer rejected the claim, stating
"No need for hospitalisation and can be managed OPD basis"

The customer took the insurer to the consumer court and won the case

What did he do to win the claim?
Let's find out in this very important claims stories 👇 Background

Mr Agarwal bought a family floater policy for his family from Star health in 2018,

The policy also covered his son.

🚨Acko Health Insurance-Is it really good Mamu?😅😅

Acko covers all diseases from day-1(except for pre-existing diseases)
Should u be tempted by the Acko policy?🤔🤔

A thread🧵on features of Acko Platinum Health Insurance and should u buy it?

Lets go👇 Acko Platinum Health Insurance:-

Some diseases such as cataracts etc come with a waiting period of upto 2 years

Acko covers all diseases from Day-1 irrespective of any health condition.

This is a significant deviation from all other policies and is friendly to the customers

🚨Restoration Benefit-One of the most important feature in health insurance?

Sum insured=5L
Claim pased=20L(in multiple claims)

🩺Niva Bupa Aspire
🩺Care supreme
🩺HDFC Ergo Optima Secure
Which policies offer unlimited restoration benefit?

A thread🧵on restoration benefit and which policies offer this benefit?👇 What is restoration benefit?

Restoration benefit is an add-on feature in health insurance policies that provides an additional sum insured amount after the primary sum insured is exhausted in a policy year

This feature may be handy for policyholders likely to use their original sum insured due to recurring illnesses or hospitalisations.

🚨Smoking/Drinking- Detrimental for health and health insurance?

If you drink alcohol or smoke, your health won’t be the only thing at risk—your insurance claim might be too.

Most insurers reject claims if your Liver cirrhosis or lung cancer is linked to smoking/drinking.😱😱(even if you declare smoking/drinking)

A thread🧵on claims due to smoking and drinking in health insurance?👇 How does smoking and drinking affect your health insurance?

Both smoking and drinking are injurious to health

For Smoking:-
If you smoke more than 6 cigettes a day no insurer issues a policy.

For Drinking:-
If you drink regulary or more than 3 days a week insurers may not issue a policy

🚨9x premium rise in 3 years-The reality of group policies,

One of our followers was lured to buy
ICICI Health Shield 360 by ICICI Bank,

The premium he paid:-
2023: 10896, SI 50 Lakh
2024: 32000, SI 15 Lakh
2025: 96000, SI 15 Lakh
9x rise in 3 years!🤯🤯

A thread🧵on group health insurance policies & should u buy them?👇 What is a group insurance policy?

A group insurance policy is a type of insurance that offers cover to a "group" of individuals with a common intent.

Banks or certain communities like Jains offer these policies.

Sum Insured=10L
Claim Amount=3L

Policy Ported in Oct'2024,
Cancer detected in Nov 2024,

Lodged a claim with Niva Bupa,
Niva Bupa rejected the claim and canceled the policy citing non disclosure,😭😭

The ported policy was 5 years old!🤯🤯

A thread🧵on claim rejection due to portability and how to avoid it?👇 How is a health insurance policy issued?

When you approach an insurer to buy a health insurance policy,
Insurer underwrites ur policy,
All existing medical conditions need to be checked whereby insurer decides if he wants to rake the risk and issue a policy or not!

Insurer has the right to reject ur policy if he feels the risk is too high.

🚨Portability Scam-Retail policyholders getting caught out

Random Telecaller asked the customer to port 2 years ago,
Sum Insured=50L
Claim Amount=5L

The new insurer rejected the claim saying pre-existing diseases weren't disclosed!
New insurer cancels the policy!

A thread🧵on scam around portability and checklist to follow while porting?👇 What is health insurance portability?

You bought a health insurance policy.
After some time when u read the policy terms and conditions.

You realize the policy has
🩺Room rent limit
🩺Copay
🩺Isnt a comprehensive policy

Now u want to change the policy!
What do u do?

🚨Super Top up in health insurance

Super top-up is like a mobile recharge!
It increases ur sum assured over and above ur base health insurance policy!

What is this super top-up?🤔🤔

A thread🧵on what is a super top-up plan and its benefits and limitations?👇 What is a super top-up policy?

Super Top Up policy offers you coverage of Mediclaim above your chosen deductible limit

It offers you financial relaxation in the event that your hospitalization claim bill crosses your sum insured under any other Mediclaim policy.

🚨Sum Insured=50L
Claim Amount=5L for heart illness

The insurer found evidence of consumption of hypertension medication,
The insurer rejected the claim saying "Fraud"
Hypertension not declared

A thread🧵on what happens if you dont disclose pre-existing medical conditions and buy a policy?👇 What is the underwriting of a health insurance policy?

Whenever you buy a health insurance?

Medical underwriting is the process of evaluating an application for health insurance coverage by examining the applicant's medical history.

If you disclose any diseases that you have had before buying the insurance.
The insurer can do three things
1. Reject your policy
2. Impose waiting period and exclusions
3. Increase the premium due to higher risk called Loading

🚨Corporate Health insurance-Is it enough or is personal health insurance needed?

At the age of 44,
Ram developed cancer,

All of his expenses were covered by corporate health insurance,
But after a few months,he lost his employment,

No health insurance company was now ready to give him a policy!
This can easily happen to u

A thread🧵on the features of a corporate cover & why u should never rely on a corporate cover? What is a corporate cover?

A Corporate Health Insurance Policy is a type of insurance that covers a group of professionals working under an organization against illness, accidents, & other health issues.

Corporate Health Insurance is basically a Group Health Insurance Plan.

🚨Term life Insurance-Which is the best term plan to buy?🤔🤔

Term insurance is the only life insurance product to buy!

What is term insurance?🤔
Which companies offer the best term plan?🤔

A thread🧵on what is a term plan and 5 best term plans that u can buy?👇 What is a term insurance?

It’s a pure risk cover that pays the Sum Assured to the nominee of the policyholder in case of death of the life insured during the policy term.

In case the policy member survives till maturity of the plan
There is no payout

🚨Term Life insurance-Myths unravalled

Term Insurance is the only life insurance to buy!
But,
🏦Should u buy term plan for 99 years?
🏦Yearly premium payment or 5-year/10-year payment?
🏦How much should be ur sum insured?

A thread🧵on an imp question on how to buy a term plan?👇 First things first:-

What is a term insurance?

It’s a pure risk cover that pays the Sum Assured to the nominee of the policyholder in case of death of the life insured during the policy term.

In case the policy member survives till maturity of the plan
There is no payout

🚨Best Health Insurance policy?🤔🤔

One of the most asked questions:-
Which is the best health insurance policy in India?

Is it
🩺HDFC Ergo
🩺ICICI Lombard
🩺Star Health
🩺Acko or someone else?🤔

A thread🧵on 7 best health insurance policies that you can choose from today?👇 First things first:-

How to choose a health insurance policy?

One must choose a comprehensive policy

https://x.com/NIKHILLJHA/status/1722062439900930354

🚨Consumables in health insurance-The most important rider?

Sum Insured=50L
Claim Amount=6L
Insurer paid=5L
Cost of consumable rider=Rs 1000

The real cost of consumable rider not being included-claim of 1L not paid🤯🤯

Does ur health insurance policy have a consumable rider?

A thread🧵on what are consumables and which policies cover consumables?👇 What are consumable items?

Consumables are usually, but not restricted to, medical aid/ equipment that have to be discarded after use. The cost incurred from the consumables is directly billed to the patient (if not covered in the health insurance policy).

🚨Ultimate Care-A copy of ICICI Lombard Elevate?🤔🤔

ICICI Elevate has revolutionized the entire health insurance industry,🤯🤯

Care has launched a new product "Ultimate Care" with
🩺Infinite bonus each year,
🩺Refund of 1st year premium in case no claims for 5 years
🩺Unlimited Restoration

A thread🧵on features of Care's "Ultimate Care" policy?👇 What is happening in the industry?

The industry is now moving to products with
1. Unlimited bonus each year
2. Unlimited bonus
3. Unlimited restoration

The policy now means super top-ups are now redundant.

So what are the features of Care Ultimate care policy?

🚨Reimbursement Claims-Problems of hospital overcharging!

Sum Insured=10 Lakhs
Claim=6 Lakhs

Insurer Paid=4 Lakhs🤯🤯

The insurer applied a clause called the "Reasonable and Customary Clause" to not pay the entire bill.

What is a "reasonable and customary clause"?🤔🤔

A thread🧵explaining reasonable and customary clauses?

Lets go👇 Reimbursement vs Cashless Claims

A cashless claim is done where the hospital has a MOU and pre-defined rates for every treatment

A Reimbursement Claim is down where the Hospital does not have MOU and pre-defined rated for every treatment

Major problems arise during reimbursement claim.

🚨Sum Insured=25L
Claim amount-4L

The insurer rejected the claim stating excessive drinking is the cause of liver damage!

Can your health insurer reject your claim due to smoking & drinking?(even if u declare it)

A thread🧵on claims due to smoking and drinking in health insurance?👇 How does smoking and drinking affect your health insurance?

Both smoking and drinking are injurious to health

For Smoking:-
If you smoke more than 6 cigettes a day no insurer issues a policy.

For Drinking:-
If you drink upto 200ml per week insurers may issue a policy but they may load the premium

🚨ICICI Lombard Elevate-A product that is driving innovation

With unlimited bonus,
Elevate has completely changed the dynamics of the health insurance industry🤯🤯

ICICI Elevate has now introduced
🩺World wide cover without any restrictions
🩺NRI discounts for Indians living abroad
🩺A massive reduction in premium increase to cover pre-existing diseases

A thread🧵on changes to ICICI Lombard Elevate?👇 How has ICICI Elevate changed the dynamics of health insurance industry?

No Claim Bonus:-

The no-claim bonus is 20% each year upto 100%.

However, this can be modified by a power booster:-

Power Booster
At the end of each Policy Year, the company will provide a Cumulative Bonus of 100% of the expiring or renewed Annual Sum Insured (whichever is lower)

This has no upper cap

🚨Random Reasons for claim rejection-Part 2

Sum Insured=10L
Claim Amount=2L

Insurer rejected claim
"Hospitalisation not necessary/Can be done on an OPD basis"

How can an insurer sitting in an AC office decide
The need for hospitalisation for a patient facing severe health issues?😱😱

A thread🧵on hospitalisation not necessary clause and how to save urself from it?👇 What is hospitalisation not necessary?

Almost all insurers use this clause to reject claims,

Insurer feels that diseases like pnemonia/fever dengue and other illnesses can be treated on an OPD basis and should not warrant hospitalisation.

However,
Each case is really very different and somethines detiriotarion of clinical parameters can warrant hospitalisation

Lets see some examples