Common reasons for difference in claimed and approved amounts

You just bought a health insurance policy, knowing that it will help to safeguard yourself and your family's healthcare needs from the uncertainty of life and cost inflation in healthcare. When it is time to settle your claim, it can be agonizing if you find a difference in the amount that you claimed and the amount that was approved by your insurer.  With this difference, there can be a considerable impact on the out-of-pocket expenses borne by a family.

Reasons for difference in claimed and approved amount

Many people are dissatisfied with the services of health insurance providers on account of their claim not being settled as per their understanding of the policy. Many a time, people are not inclined to find out the reason for the difference in the claim value, However, the difference in the claimed and approved amount can be due to various factors, two of the most important ones being:

  • Not reading the policy inclusions and exclusions
  • Wrong choice of health insurance plan
  • Waiting period – during which no coverage will be offered

As a policyholder, you must provide your health insurance company with appropriate facts and information when you buy a health insurance plan. Incorrect information often leads to rejection or a difference in the claimed and approved amount depending on your policy terms and conditions.

Reasons attributed to policy terms and conditions

Listed here are some common reasons for this difference, which are as per the terms and conditions stated in the health insurance policy:

  • Non-Medical expenses. To know the list of items that are non-payable click here.
  • Admission in a room with a higher room rent than as per eligibility and proportionate deduction
  • Co-payment/ Ailment cap / Policy restrictions
  • Irrelevant expenses (Consultation, lab, pharmacy, etc…)
  • Improper bill format / Non-submission of receipts / breakups
  • Pharmacy and Lab claims without prescription
  • Pre and Post hospitalization value exceeding limit as per T&C
  • Deviation in PPN rates
  • Part-payment of treatment
  • Claim for duplicate/copy bills.

So choose our health insurance plan wisely and pay close attention to the policy terms and conditions to avoid any confusion later on!