Accidental injury claims in health insurance: What you should know

Accidents do happen, and when they do, they shake us up. We’re caught off guard, we’re not prepared. And not just the person who is involved in the accident, the whole family, friends and colleagues have to come to terms with it. Accidents can happen due to our mistake or sometimes due to the mistakes of others. A sub-part of accidents is injury. An injury may happen unexpectedly or it may be the result of self-harm. A brawl, car collision or an attack that grievously hurt may even lead to a police complaint. Thankfully, health insurance comes in handy to cover the sudden financial shock. In this article, we will look at accident claims in deep detail.

Coverage in insurance policies

Accidents or injuries can be segmented in two ways for the purpose of understanding insurance coverage – (1) Externally caused and (2) Self-inflicted. Externally caused injuries could be because of a road accident resulting from collision of vehicles, or someone getting hit by vehicle or other objects, or due to an attack by somebody or some animal. On the other hand, self-inflicted injury only involves the patient. He or she may have fallen from a chair or some other surface, or maybe slipped or cut themselves by accident. However, there are some forms of self-inflicted injuries which show intent of self-harm, such as attempting suicide by use of poison or jumping from a higher surface or injuring oneself by cuts from sharp objects. Injuring oneself while driving under the influence of alcohol or other narcotics or any other adverse incident resulting from the use of drugs etc. are also forms of self-harm.

Insurance policies cover treatment for all forms of accidental injuries or damage, except when it becomes known that the injuries resulted from an act of self-harm. One cannot expect insurance to pay when the injury is because of one’s own actions. Insurance policies also do not cover injuries which can be attributed to war, invasion or nuclear weapons/material.

There are no separate limits on cover for the treatment of injuries. In fact, while a majority of insurance policies do not cover dental treatment or plastic surgeries, such procedures are covered for accident cases.

Surgical and medical management

Whether your treatment requires surgical intervention or the injuries can be managed conservatively during a hospital stay, your insurance policy will cover without any limit.

Emergency expenses

All insurances pay for ambulance charges, if any, needed for the transportation of a patient to the hospital. There are generally limits defined on how much insurance would pay, but ambulance charges are recoverable.

Before admission to hospital, a patient may be received in the Emergency or Casualty of the hospital. Investigations such as X-ray, CT, MRI and many other lab tests may also be conducted to assess the condition of the patient before deciding to admit him or her. Some hospitals charge separately for Emergency care and this is not part of the hospital bill. Even if you got cashless for the hospital bill, you can claim your Emergency bill towards the Pre Hospitalization expense reimbursement claim.

Shifting from one hospital to another

If the patient has to be transferred from one hospital to another one as the patient requires care at a higher medical centre, the expenses borne at the first hospital are also covered under Pre-hospitalization expenses. The patient is not required to have stayed in the first hospital for 24 hours if directly the patient has been shifted to the next hospital based on the written advice of the treating doctor of the first hospital.

Blood bank charges

Certain injuries necessitate blood transfusion to the patient. If the hospital doesn’t have an in-house blood bank, then the patient’s family or attendees may source blood from outside the blood bank by paying for blood bank charges. If the patient has been admitted under cashless hospitalization, these charges will not get added to the cashless bill. Instead, the patient has to claim these blood bank expenses separately as reimbursement claim.

Post-discharge recovery

Depending on the severity of injuries, patients may take less or more time to recover. During the recovery period, patients need to revisit doctor for follow-ups, undergo repeat X-ray scans to monitor healing of joints and some patients may have to undergo multiple sessions of physiotherapy to be able to move their limbs without pain. Insurance policies cover these post-hospitalization expenses for a period of 60 days from the day of discharge. In some policies, this duration may extend up to 120 days. A patient has to go for reimbursement claim to recover these expenses.

What to expect in claims?

In medico-legal cases, it is important that the hospital does proper documentation of the Medico-legal certificate (MLC) and you get a copy of the same. If the case requires filing of a policy case, then it is also necessary to maintain a copy of the FIR.In case a patient indulged in drunken driving then the insurance company will not approve the claim. One can expect tight scrutiny of claim documents.

Especially in cases of self-inflicted injuries, sometimes family members do not intimate police and even try to influence the hospital to not file MLC and suppress facts of the case. The circumstances leading to injury are very important in self-inflicted injury claims. Insurers may probe extensively and take all kinds of declarations from hospital, doctor and patient and even interview witnesses and examine patient physically.