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Category: Blog

28 Dec 2018

Renewing your Health Insurance Policy – Things To Remember

Your health insurance policy is usually valid for a period of one year from the date of registration. Before or as soon as this period is over, you need to renew your policy in order to keep enjoying the benefit of continued coverage.

Here are 6 things you need to keep in mind:

  1. Never procrastinate when it comes to policy renewal. If you forget to renew it by the last date of your policy, remember to at least finish the renewal before the “grace period” expires. Note that the “grace period” is only for renewals, and you are not covered on these days. A medical emergency during this period can be devastating.
  2. Whether or not you have made any claims in the last year, you have invested in the policy, month after month. If you decide not to renew it, you lose out on benefits like no-claim bonus and coverage on health checkups. Some insurance companies may even increase the sum insured to you on renewal, without increasing your premium.
  3. Almost every policy has an initial waiting period of 30 days from the date of registration before it begins to cover your medical expenses. If you forget to renew your policy, you will be forced to re-register as a new policy and will need to wait another 30 days before the coverage kicks in.
  4. For treatment of pre-existing diseases and (in special cases) maternity, there is usually a waiting period of one or two years. If you miss out on renewing your policy on time, you also lose the one year you have waited and will need to begin your waiting period from Day 1 once again.
  5. Before the validity of your policy expires, consider other policies that may be available with the same insurance company or a different one. As per the  Health Insurance Portability provision made by the Insurance Regulatory and Development Authority of India (IRDA), you can transfer from one policy to another without losing out on no-claim bonus, waiting period and the like. However, this can only be done if you apply for the transfer well before expiry as there may be some processing time required.
  6. The policy you opted for one year ago may seem obsolete now as your family may have changed (if there has been a birth or death), or if you feel that your medical needs are now different. This may leave you with a tendency to allow the policy to expire. Instead, we suggest that you use the last month of your policy period as an opportunity to revise your coverage, increase your sum insured or make any other changes you may need in terms of the policy in a timely manner without losing out on continued coverage.
21 Dec 2018

How is your Health Insurance Premium Calculated?

Insurance premium is the amount of money the insurance company levies the policyholder for the insurance policy. In order words, the premium is the price paid for the policy. Often the policy premium is paid in monthly installments and sometimes, the entire amount is paid in one or two installments on an annual or semi-annual basis.

You may have noticed, while searching for a policy, that different policies quote different premium amounts. Sometimes, the same insurance company may quote a different premium amount for you and someone else who is opting for the same policy. So, what really determines your premium?

At the base of it all, most policy premiums are calculated keeping in mind the marketing/administrative expense, how much the insurance company wants to use for savings and how much it will reinvest, the medical underwriting which takes into account various types of risks (to prevent loss for the company), and so on.

In addition to these, the following factors also affect your insurance policy premium:

  • Type & extent of risk coverage

There are, often, a wide range of options provided by insurance companies when it comes to the type of policy one can opt for. There are policies that cover only treatment costs, and there are ones that cover room rent as well. Therefore, depending on the extent of coverage offered by the policy you choose, the premium will also vary.

  • Policy-related payments

While it is obvious that the total sum insured will directly affect the insurance premium you pay, there are also a few other payments known a deductibles that can affect your premium. If, for example, you are willing to opt for a higher co-pay, then your insurance premium might be lesser.

  • Your personal information

Your age

Your age is considered to be one of the factors affecting your health and, therefore, it is also one of the factors affecting your health insurance premium. The older you get, the more susceptible you are to ailments like diabetes or blood pressure, and your treatment costs would be reasonably higher due to these underlying ailments.

Insurance companies have set “bands” based on different age groups (for example persons from age 26 – 35 years belong to one band and those between 36 – 40 years belong to the next). It is said that the premiums from one band to another can vary between 30-60%.

Your medical history

Your medical history and your personal habits that can affect your health (drinking, smoking etc.) affect the amount you pay as premium for your health insurance.  Even your family’s medical history will be taken into account, as you are at higher risk of acquiring certain diseases if a family member has it already.

Your BMI

The body mass index (BMI) speaks volumes about your current health status. This calculation involving your weight, age and height determines if you carry a healthy weight or if you are underweight/overweight. Those found to be overweight may be at a higher risk of certain diseases (including heart problems). Some insurance companies may even require you to go in for a health checkup before signing you up for a policy.

Community Rating

Where you live can have an impact on your health and, therefore, on your health insurance premium. For example, if there is a factory emitting toxic elements into the air/water in your neighbourhood, you may be prone to a certain sickness due to these factors. Insurance companies, therefore, provide ratings to different localities and this can affect the premium you pay.

Family size (for group policies)

If your policy is for an individual, the policy payments are calculated accordingly and if you opt for a policy that will cover your family, then the number of individuals the policy covers will affect the calculation of the premium.

  • Market Competition

When two or more insurance company agents are trying to get a large policyholder (like a company which wants to provide health insurance to employees) to sign up with, the competition may cause slight variations in the premium amount they quote. As the policyholder is likely to choose a policy with a company offering the lowest premium for the same benefits, this is likely to happen.

14 Dec 2018

What to do if your health insurance claim is rejected

Imagine this scenario: you have been paying your premiums towards health insurance, month after month, and you made a claim for a particular healthcare treatment you received. However, the insurance company (or the TPA, if one is involved) gets back to you saying that your claim has been rejected. Would you be frustrated? Without a doubt, and rightfully so! You have been regularly investing your money in the health insurance company for the very purpose that, when you have a medical need/emergency, you will not have to run about for the money. If the insurance company rejects your claim in such a situation, it will be stressful for you – both emotionally and financially. We hope that you never have to go through such a situation, but we would like you to be prepared in case the need arises.

There are 3 major factors that affect the fate of a claim. They are:

  • The medical necessity of the treatment
  • The correctness of the details filled in the claim
  • The inclusion/exclusion of certain healthcare procedures as part of the policy

Here are a few steps to consider if you are ever faced with a health insurance claim rejection.

1. Question yourself

Everybody makes mistakes and, in this case, it could have been the insurance company or it could have been you. Before you go about taking any kind of action in response to the claim rejection, ask yourself these questions to find out if there has been a mistake at your end.

With regard to your eligibility in the purview of the policy:

  • Did you have a pre-existing disease that you did not disclose to the insurance company while purchasing the policy?
  • Was there a waiting period for pre-existing diseases that you may or may not have notified to the insurance company about? Was your recent hospitalisation connected to this pre-existing disease?
  • Was your claim for a cosmetic surgery or some other non-curative treatment? If it was a dental treatment, is it something covered by your policy?
  • Was the hospitalisation only for diagnostic purposes and not for actual treatment?
  • Did you inflict injury on yourself – such as a suicide attempt or a condition caused by your drinking or smoking habit?
  • Was the treatment you availed related to any other permanent exclusions mentioned in the policy document? These could be congenital or genetic diseases, injury during war, etc.

With regard to your claim:

  • Did you submit the adequate documents as required?
  • Did you make the claim in a timely manner? Most claims need to be made within a certain number of days/weeks after the hospitalisation.
  • Did you make your claim during a waiting period?
  • Has the date of your insurance cover expired or has the sum insured been exhausted?
  • Did your claim exceed the permitted sub-limit applicable for the particular treatment?

Once you ask yourself the above questions, you will know (more or less) if the claim was rejected because of an error at your end. However, if you are convinced that you have done everything right, then you can proceed to investigate further.

2. Read the adjudication report

The insurance company is required to state a valid reason for the rejection of your claim. In the case of a cashless claim, this report is sent to the hospital and in case of a reimbursement claim, it will be sent directly to you.

Reading through this report may give you answers and help you take the next steps.

  • Sometimes, there may have been an error in the way the form was filled. If it is something that can be rectified (such as a spelling error or a customer number error), you can inform the TPA with a request to reopen the case and/or reapply once again.
  • If your claim was rejected due to insufficient proof/documentation, then you can reapply after checking and collecting the required documents. You may need to make a few trips to the hospital for these, if you don’t have them already. Sometimes, you may have simply forgotten to attest a document, and this could have caused the rejection. In case of this and the previous scenario, remember to reapply before the window period for submission expires.
  • If the reason for rejection was that the treatment you availed didn’t seem necessary to the insurance company, go back to your doctor and collect a letter explaining why the treatment was necessary at that point. To strengthen your argument, you may also meet another doctor (who did not treat you for this) and get him/her to vouch for the validity of the treatment as well.

3. Contact the TPA/insurance company

It is highly probable that a claim was rejected due to an error from the insurance company’s side. If you have a valid argument and adequate proof, then you can get in touch with the TPA or insurance company and request them to reconsider your claim. Here’s how you can do it:

  • Write a formal letter/email with a clear title and a clear, understandable statement that validates your claim.
  • Attach appropriate documents (along with letters from doctors) with their medical opinion on why the treatment was necessary.
  • Await a response from the insurance company. However, if you do not receive a timely response, you may escalate the issue with a higher authority of the insurance company.

If your reasons seem valid, chances are that your claim will be accepted (either fully or partially) at this point. Ensure that you maintain a copy of every communication that has transpired between you and the TPA or insurance company regarding this case.

According to an article by Forbes, it is perfectly acceptable to re-apply the claim and/or appeal for the claim as many times as you want. Sometimes, if you give up too soon, you may lose out on what you rightfully deserve – especially if the insurance company is not genuine and is rejecting your claim simply to make a profit.

4. Seek a lawyer’s help

If none of the above work out and you are still fully convinced of the validity of your claim, make an appeal opposing the insurance company’s decision with the help of a lawyer. Remember that this is the last straw, and that you may be wasting your time, money and energy if your appeal is made against a valid rejection by the insurance company.

While making an appeal, make sure you have a copy of all the relevant documents with you – starting from hospital bills to all the communications (including emails) made regarding the claim between you and the TPA/insurance company. If your appeal has been found valid, you will be rightly rewarded by the approval of your claim.


03 Dec 2018

Claims Adjudication Made Easy

Claims adjudication, sometimes known as medical billing advocacy, refers to a process where the insurance company reviews a claim it has received and either settles or denies it after due analysis and comparisons with the benefit and coverage requirements.

The process begins with receiving the claim, either directly from the policyholder or from the healthcare provider (in case of health insurance).

Once the process of adjudication is complete, the insurance company make the payment and/or sends a letter to the claimant, describing the company’s decision to accept or reject the claim, along with validating reasons for doing so. nd how the amount to be paid was determined. This is known as the remittance advice or, more popularly, Explanation of Benefits (EoB).

The letter also includes, for an accepted claim, detailed information about how each service included in the claim was settled and how much is being paid for them.

Problems Faced in Claims Adjudication

The claims adjudication process is riddled with challenges because:

  • Claims are submitted through a variety of mediums – electronic and manual
  • A dedicated workforce is required to manually verify each claim and filter and investigate suspicious claims through a long and cumbersome process
  • Manual rule-driven mechanisms are time consuming and pose threats like loss of customer base due to delays or perceived harassment over submitted claims
  • Erroneous rejection of genuine claims or delayed settlement of claims can cause customer dissatisfaction
  • Several billions of rupees are lost due to fraudulent claims each year, missed out by inefficient adjudication process

The Attune-ABI Solution

Attune ABI has developed a software, HealthClaim Hub, which can automate most of the claims adjudication process using techniques of artificial intelligence including machine learning, text mining, and deep learning.

The major functionalities of the HealthClaim Hub are:

  • Conversion of claim data from existing PDF formats (patient details, diagnosis details, diagnosis tests, treatment details and bill summary) into structured formats (mines reports, notes)
  • Points out to anomalous elements within claims (bills for diagnosis tests, procedures, medicines or actual prescribed diagnosis/treatment path for the patient)
  • Flagging of suspicious claims at individual and hospital levels with a high degree of sensitivity so that insurance companies can give manual attention only to flagged claims
  • Payment determination is made easy through HealthClaim Hub as the system uses big data analysis to estimate the average and reasonable amount usually charged for specific services

The automation of the claims adjudication using HealthClaim Hub makes the entire process of claims adjudication easy, effective and efficient. More claims can be processed in less time and the time, money and manpower invested in adjudication can be reasonably brought down. The improved turnaround time in responding to and settling of claims leads to improved goodwill among customers and other stakeholders. In other words, HealthClaim Hub smoothens the claims process for the healthcare provider, the policyholder/patient as well as the insurance company involved.

26 Nov 2018

5 Reasons Why You Need Health Insurance Now!

The More You Wait, The More You Pay

When it comes to health insurance, age is an important factor. Insurance companies offer health insurance at a cheaper premium for younger people as they tend to have fewer medical problems and lesser chances of making a claim. As you get older, not only will you need to but also pay higher premiums, you will also need to undergo a medical test and prove that you are fit in order to be accepted into a health insurance plan. If a ‘pre-existing disease’ is identified during the test, your application may be rejected or you may be forced to go through a ‘waiting period’ before getting coverage.

If you get enrolled in a plan while you are still young and healthy, you will continue to pay the same premiums as you age and will be covered for any diseases that are diagnosed while already covered.

Treatment Costs are Skyrocketing

If you are hesitating to part with your money to pay for health insurance premiums, consider this – healthcare costs are increasing by the day and will continue to rise!

The Global Medical Trends Report shows a 12.5% inflation in medical treatment costs, particularly in India during the year 2017. While it is true that we see breakthrough after breakthrough in the medical research, science and technology industries, these new and improved treatment methods are also highly expensive and inaccessible by the middle class. Without a health insurance policy, paying for such treatments would be unimaginable and put you at the risk of availing debt with cut-throat interest rates.

An Emergency Occurs When You Least Expect It

In the prime of our lives, we tend to think of health insurance as an unnecessary or even a foolish act.

Think about it – stress, itself, can lead to multiple health complications, adding to the woe of pollution, the contamination of water, the toxicity of chemical-pumped vegetables and meat, to name a few. Even if you do manage to eat and live healthy, diseases like cancer can come when least expected. Not to scare you, but accidents are called accidents simply because of how unexpectedly they occur.

Your Employer’s Health Insurance is Not Enough

A lot of people tend to dismiss the idea of investing in a health insurance under the premise that their employer has already covered them under a group insurance policy. However, such policy covers are highly limited and may not be applicable for your specific treatment need. And by the time you find out, it may be too late to look for an alternative source to pay for the treatment. Sometimes, there may be an overall limit for the group, and if someone else in the same group policy has availed a part of it, it may not be sufficient for you.

Moreover, if you lose or leave your job, you will lose your insurance cover as well. The worst possible time to be uninsured is the time when you are between jobs!

Why Deny the Tax Benefits?

Everybody loves a little savings on income tax, so why not set aside a portion of what you might otherwise have to pay as taxes for investing in your own health?

As per Section 80D of the Indian Income Tax Act, a person with a health insurance policy can save up to Rs. 25,000 (or Rs. 30,000 for senior citizens) annually depending on the premiums paid towards health insurance. Additionally, there is also an additional Rs. 5,000 you can save for expenses incurred for health check-ups for yourself as well as your dependent family members. It is almost like getting paid to stay healthy, so why not?

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