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Health insurance turns out to be a genuine privilege most of the time whenever there is any unexpected health hazard occurs. The intrinsic purpose for which people get health insurance is because it renders all the expenses including the hospitalization cost, both pre and post, ambulance, medicines, day-care fees, etc.

Health insurance acts as a shield to your bank account when and if any need that requires hospitalization comes during the policy period.

There is a myth circulating that health insurance only covers hospitalization expenses which is not true. There are a lot of expenses that go unclaimed due to the same reason. The best insurance plan will provide you the cover for all the expenses including your medicines, ambulance, per day hospital charges, etc. If you are facing problems in the claim process, you can also file a complaint against Health Insurance Company which we will discuss later in this article.

Some key benefits of having a health insurance policy are listed below.

Why A Health Insurance Policy

The proportion of growth in one’s earnings and the growth in expenses in taking health care is not in sync at all. One cannot bear the expenses if he/she has to do some regular check-ups due to some illness. Here, we will talk about all the comfort and luxury of having the best insurance policy for yourself. why health insurance policy

No Cash Needed: All health insurance companies have a list of hospitals from where they have tie-ups and if you get your treatment done from these hospitals, there will be absolutely no cash needed in any of your medical needs. 

All Expenses Covered: The best health insurance policy will cover all of your expenses including the expenses incurred before getting admitted to the hospital and even the expenses which are levied upon you after being discharged. The policy will cover a fixed number of days before and after getting hospitalized.

Medical Check-up: If you have a history of not claiming the policies, some insurance companies also provide you the provision of getting insurance for your regular check-ups. 

Tax Benefits: This provision is in the Income Tax Act, under section 80D, that you will get a rebate from tax if you are enrolled in any health insurance policy. Also, the rebate is not determined by the amount you pay as a premium but it comes with a cap and is subjugated on the policy holder’s age. You can save up to INR 25,000 if you are below the age of 60 and if you are above that, you are entitled to get a rebate of INR 30,000.

Consider These Before Getting One

A list of doubts and a pool of dilemmas get birth when it comes to getting a policy for yourself. Here are some factors you should contemplate.

Sub-limits: There is an entry point on each insurance policy in the form of caps and sub-limits. If a policy is stating these then there are many chances that this policy will cover almost all the expenses. To extract the full potential of your policy, there is a dire need for understanding these factors.

Settlement of Claims: You must check what is the insurance company's claim settlement ratio. If it’s low then this company will give you many troubles in the future. However, if you forgot to tick this criterion at the time of getting the policy, you can always file a complaint against the Health Insurance Company.

Family Size: This point is a must because every family has a different number of members. You should cross-check with the company if all the members come under the policy or not.

Scope: It doesn’t always translate to a great policy if it requires less premium. You must check all the aspects before paying the premium. Having a policy that will work is wise as well as practical decision rather than getting a low premium one and get minimum coverage. 

Restore Benefit: In case you made the expenses, it may happen that the plan you are going to take offer the facility of restoring the benefits. While getting a plan for yourself, you must consider that if there is not an option of restore benefits, you could ask for the top-up packages at affordable rates.

Prevalent Frauds

The insurance sector and precisely the health insurance is a very fast-growing market. Still, the industry is suffering from huge losses now and then. The fraud in this sector is done by false representation of the facts and getting the amount for anything else claiming it as in health-related needs. 

The frauds are executed in an array of aspects and can be done by both the insurer as well as insured. The government also provides you the provision of filing a complaint against Health Insurance Company. Here are some very common types listed below.

Opportunity Fraud

This type has those frauds which are shown as natural occurrence but in reality, they are calculated and put in such a way that the act which they are trying to take the claim for comes under the policy terms. It can also be done in a way that a genuine accident is shown in an over-taunted way to get the insured amount as much as possible.

Frauds From Internal & External Factor

The frauds which are done by the external factors are considered as the frauds done by policyholder himself, or any beneficiary and medical vendors, etc. Whereas internal frauds are executed by an inside person against the policyholder. The person inside the company can be anyone from the manager to any executive or agent.

Fraud Based on Eligibility

The eligibility fraud is also a misrepresentation or falsely putting up the facts before the insurer. The false information could be anything like age, actual salary, the existing disease from which she/he suffering, or the people dependant on him/her. A prime example can be taken of a part-time employee who is not entitled to the benefits as one of the full-time employees. By taking the help of an HR person, he successfully generated false records and the reimbursement was made.

Fraud In Application

This is one of the most common fraud categories which is witnessed in the health sector where the insured provides false information regarding the existing illness. He might not talk or give any information about it at all just to get some more time in the policy. Sometimes, the employer tampers the date when the employee joined to get the approval of the claim from the insurance company.

13 Frequently Asked Questions on Health Insurance

Now, what if the insurance company itself executes any fraud against the insured, what a policyholder can do. Let’s discuss this.

IRDAI: Body Where You Can File A Complaint

There can be any situation where you are not fully content with the insurance company and you have all the proofs that not you but the company is at fault here. There is no need to panic that no one will provide you the justice and insurance company will take all your money. You can file a complaint against Health Insurance Company in IRDAI, Insurance Regulatory and Development Authority of India. This government body will help you with all the aspects and can escalate the matter real quick.

A rule has been stated clearly in the Protection of Policyholders' Interests Regulations, 2002 of IRDA which has put the companies in a Turnaround Time for almost all the services they render. Based on the type of redressal system of complaints, turnaround time has been fixed for all the health insurance companies as well as general insurance ones. 

If the company from where you got insured is not resolving your time within the set TaT by IRDA, you can immediately approach the governing authority to provide you the solution. The process will not be delayed by the IRDAI and the matter will be discussed with the company on an urgent basis. 

If for any further process, any inquiry or court intervention is sought, the insured then has to file a formal complaint to the consumer court.

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The Process Of Lodging a Complaint

You can’t directly reach to IRDA for the redressal of your complaint. First and foremost, you have to go to the company’s grievance cell, generally located inside the branch itself. The complaint submitted should be in writing without missing on any point and all the supporting documents must be at one’s disposal. 

The company will then provide you the written cognizance of your complaint along with the submission date. The vogue time that these companies take to fully resolve your problem is 15 days. If not, then you have every right to take the matter to IRDAI and request the governing body to address your grievance and provide the solution. 

Here’s a list of utmost TAT for the redressal of some complaints.

  • For issuing or canceling a policy, it is 15 days.
  • 30 days to obtain a copy of the proposal of the policy.
  • Service request for refund or NCB, it is a maximum of 10 days.
  • 6 months is the maximum TaT in case of death settlement.
  • 10 days for all the matters related to surrender.
  • 3 days to concede the grievance.

You can file a complaint against Health Insurance Company in IRDAI by writing a proper application through an email and send it to complaints(at)irda(dot)gov(dot)in and also you can call on their helpline number 1800 4254 732.

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Naval Goel is the founder of He is an Associate Member of the Indian Institute of Insurance`, Pune. He has been authorized by IRDA to act as a Principal Officer of Insurance Web Aggregator.
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