Often we hear when someone already has Health Insurance, it turns out when the concerned was treated for illness, apparently his claim was not paid. This often results in insurance being labeled as a fraud because it does not pay the claim of the person. But on the other hand, we also see, many people whose maintenance costs are paid by insurance, even with a value far greater than the cost of treatment that claims are not paid earlier. Why are people paid, and some are not paid? Even if paid, may be paid only partly and some are not paid. Here we need to understand the terms and conditions of a claim can be paid. What are they?
Many terms and conditions of a claim can be paid or unpaid, I will try to dissect them one by one. Hopefully with this article, people can understand the terms and conditions of Health Insurance claims.
There is a waiting period in the health insurance policy, a period in which if the intended treatment during the waiting period occurs when the waiting period is not over, the cost of such treatment will not be guaranteed. The waiting period is calculated since the policy period begins. Waiting period that is often attached to health insurance policy that is:
- Waiting period of 12 months for treatment caused by certain diseases in which the list is mentioned in the policy. Diseases that usually fall into this category are cancer, tumor, kidney failure, heart attack, appendicitis, and others.
- A 30-day waiting period for treatment caused by diseases not included in a particular disease.
As for the treatment caused by accidents are usually not subject to waiting period or in other words directly guaranteed since the policy rises. Some health insurance products also exist that negate the waiting period for certain diseases so that all the diseases that are guaranteed (not included in the exceptions) will be valid since 30 days same with other diseases. Make sure you know the types of diseases that are subject to certain waiting periods according to the policy.
Each insurance policy includes an exception clause, including health insurance. This clause describes what conditions are not guaranteed in the policy. Some examples of exceptions are suicide, war, natural disasters, drug abuse, congenital conditions, pregnancy, beauty surgery, non-medical costs, AIDS / HIV, alternative medicine, and etc.
Some of the actions at the Hospital by doctors sometimes exist that are not actually required medically, usually due to the patient’s request or the patient’s family. The cost of care that can be guaranteed must be consistent with the diagnosis and medical treatment in accordance with the usual medical practice for the handling of accidents or illness suffered. One example is the demand for inpatient care by the patient in fact the act can be done with outpatient only.
Not all maintenance costs can be replaced by the Health Insurance you have. The type of action is limited to a certain limit. For example, for surgery costs at the limit of 50 million per surgery, the cost of doctor visits 150 thousand per day, and the limit of other actions. For this you need to look at the benefit table in accordance with the Plan options you have. Some other Health Insurance products exist that do not limit the cost per action. For such products, the limit is usually limited from total claims within 1 year, and is limited to the maximum room rate or class.
Type of Warranty
A popular type of guarantee is inpatient care, which means a guaranteed treatment only if the patient is hospitalized with a minimum number of hours (usually between 6-24 hours). Usually hospitalization is accompanied by limited outpatient coverage, which is usually only an outpatient guarantee that occurs within a few days prior to inpatient treatment, as well as outpatient care as follow-up care after inpatient care which is usually a maximum of 30-90 days after removal of care stay. Other types of guarantees available are outpatient care, pregnancy / childbirth, dental care and eyeglasses. These guarantees are usually more popular for corporate customers because of the higher risks.
Pre Existing Condition
That is a condition that already exists on the insured before the insurance period begins. Such conditions are usually no longer guaranteed by the insurance company. So when treatment due to the condition occurs within the period of insurance coverage, then the cost can not be paid. Unless from the beginning the insurance company agrees to such conditions on the basis of information of the prospective insured regarding the med history. Unless the insurance company accepts the condition from the start on the basis of the insured candidate’s description of his medical history.
There are provisions where care can be taken. Indonesia only, Asia alone, or the whole world, or with the exception of certain countries. So if you are treated in the area, the insurance will not provide a guarantee of claim payment. But some insurers provide conditions for guarantees outside the guaranteed territory, provided the treatment is caused by an emergency, such as an accident while traveling.
Incomplete Claim Document
It does not mean that his claim was rejected, but his claim will be suspended, until the required documents can be made available by the claimant. In submitting health insurance claims made by reimbursement, the required documents are:
- The claim form (original) provided by the insurance company filled by the treating doctor;
- Receipts (original) along with details of costs from the hospital or clinic;
- Copy of prescriptions in the case of medicines purchased outside the Hospital or clinic. The copy of the recipe is written behind the receipt of the purchase of medicines;
- Supporting document of care, eg result of laboratory examination and medical record;
- The identity of the insured and the policyholder, along with the copy of the account book as the purpose of payment of claims by the company.
Pieces of Claim or Deductible
Not all Health Insurance policies are in place. There are only a few specific products, which aim to lower paid premiums. So that each claim value submitted will be deducted by the amount of the discounted value stated in the policy. Also make sure that all documents can be submitted within the time specified in the policy to make the claiming process more current (usually 30 days to 90 days).
Policy Lapse / Cancel
If all of the above conditions are appropriate, but the Health Insurance claim submission remains rejected, most likely the policy you have lapse or canceled. Make sure you have paid the premiums that become your obligation before the maturity is fixed on the policy. And if your Health Insurance policy is a Unit Link insurance package (insurance with an investment element), make sure the cash value contained in the policy is sufficient to cover all the fees imposed on the policy.