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What are The Right Steps to Take When Group Health Insurance Does not Cover a Planned Service?

By December 17, 2021January 23rd, 2022No Comments
What are The Right Steps to Take When Group Health Insurance Does not Cover a Planned Service - Plancover

Step to Take When Your Group Health Insurance Does not Cover a Planned Medical Service

Health insurances are the supporting resource during medical emergencies. The insurance provides financial help when the policyholder gets hospitalized for necessary medical treatment. The annual renewal of the policy helps in continuing the plan benefits and insurance coverage. 

Group healthcare insurances are the non-life Mediclaim plans that an employer provides to their employees. Organizations, businesses, and startups offer such benefits to their employees in return for their service. The employer pays the annual premium charges and, the employees and their family members (if applicable) enjoy the policy benefits. There are specified terms to all group healthcare insurances that determine the plan coverage and valid claims. But what can you do if the insurance company denies a claim or does not cover a planned service? Read along to understand the effective ways to resolve it. 

A regulated system

IRDAI or, the Insurance Regulatory and Development Authority of India, under the Ministry of Finance, is an insurance regulatory body. The primary objective of IRDAI is to regulate the norms and provide legally accepted guidelines for insurance companies in India. Every insurance company (semi-government or private) needs to get enlisted under the approved names of IRDAI to sell their insurances to the people in India. IRDAI provides an outline for all the insurance companies to determine the treatment coverage and plan benefit aspects. 

In case of claim denial – Irrespective of the insurance company from where you have bought the group medical insurance, you can always address the IRDAI regulations to understand the right policy terms and rules. If your insurer does not cover a planned service against the general rules of the policy terms, you can take up the matter through IRDAI. However, before taking an appropriate step, you should check the policy coverage norms to understand the supported treatment plans. Many uncovered treatments are there (cosmetic surgery, dental surgery, etc.) that may or may not be part of your selected insurance plan. Ensure to check the terms before planning treatment. But if the insurance company rejects your claim against the norms, you should file a complaint through the IRDAI grievance unit for an effective outcome. 

Steps you can take

Multiple ways are there through which you can resolve the matters related to the non-coverage of planned medical services. Before taking any appropriate step, you need to understand why the treatment is not getting covered. Either the treatment benefit is not under your group healthcare policy features or there is a claim rejection. Insurance companies can reject the treatment coverage or claim for valid reasons. The representatives of the specific company can elaborately describe the reason for rejection (if any). But if the rejection is based on invalid grounds, you may file a complaint by connecting to IGMS (Integrated Grievance Management System). 

QR Code of Form and Online Complaint IGMS
QR Code of Form and Online Complaint IGMS

In order to protect the interests of the Policyholders,  IRDAI has framed  Protection of Policyholders’ Interests (PPHI) Regulations 2017

https://www.policyholder.gov.in/uploads/CEDocuments/policyholder%20complaints%20registration%20form.pdf

  1. Approach the insurance broker

Insurance brokers are not only your assistants in buying the right policy, but they also help you to understand the policy terms. Going for an insurance broker cum consultant company will resolve your queries. Specify the group Mediclaim policy details to the insurance consultant and they will help you figure out the right ways to manage the treatment expense of the planned medical service through insurance coverage. The possible suggestions they could make are – add-ons, insurance top-up, switching policies, or getting a personal Mediclaim. 

  1. Connect to the customer service of the insurance company

There can be nobody better than the insurance companies to specify the norms regarding plan coverage. If the healthcare plan does not support the claims of a planned service, there may be varied reasons like the following – exceeded insured sum limit, beyond the coverage terms in the policy, partial support of similar treatments, the compulsory waiting period-related issues, or no-restoration plan benefits. 

The customer representative can explain what went wrong and also provide you with resolving techniques to help you out. They may suggest buying add-ons, top-ups, or trying out customization of policy to ensure treatment coverage of the planned service in concern. 

  1. Add-on benefits alongside the existing plan

Just like an individual Mediclaim, a group healthcare policy also gives you a chance to add plan benefits, to cover a planned medical treatment outside the coverage norms. Most group health insurances have a basic plan of Rs.1lac to Rs.5lacs depending on the employer’s choice. The plans are generic with no added advantage related to pre-existing ailments or critical diseases. The policyholder can buy add-on treatment plans like – diabetes coverage, cardiac ailment coverage, corona treatment expense coverage, and much more. This way, the policyholder can include the planned treatment under the coverage sphere of the selected group healthcare insurance. 

  1. Top-up for increasing the insured sum

One reason why your planned medical service may not fall under the coverage domain is for the insured sum limit. Usually, most employers of small to mid-capacity organizations opt for Rs.1lac to Rs.3lacs sum insurance. In such cases, the insurance cannot cover the expenses completely for some treatments. You can connect to the insurance company and ask them about provisions to increase the sum limit to eliminate the plan coverage boundaries. Group healthcare insurances have this feature and for that, you have to consult with your employer and the insurance company representative to manage the extra expenses. 

  1. Check the waiting period

Another prime reason behind the non-coverage of a planned medical service may be due to the waiting period. In group health insurances and any other healthcare plans, the waiting period is the term when the insurance company does not support any claims or expenses for particular diseases (pre-existing or critical illnesses). You can either wait till the completion of the waiting term or ask the insurance provider to offer alternative ways to manage the situation.  

Port the insurance

If you cannot find any provisions to manage the treatment coverage or expense, then change the insurer. By the guidelines of IRDAI, you can port the insurance to another registered insurance company in India without losing the earned credits like waiting period and seniority. However, as this is a group healthcare plan offered by your employer, you have to consult with your employer to take the next step. 

Who can guide you the best?

Insurance companies have varied insurance coverage benefits and attributes. Not every company offers similar coverage for planned treatments. Even if you are considering getting a cataract operation, the coverage terms may be different from the other insurance companies. So, in such cases, you should always check the coverage regulations and exclusions before planning medical treatment. If it is a medical emergency, then you cannot do anything and bear the cost without insurance support. But if it is a planned medical operation, always connect to the insurance company representative to clarify the coverage benefits. They are the best ones to guide you with such matters and provide solutions for the excluded treatment aspects. 

PlanCover – Assisting in every step.

The highly reliable insurance broker, PlanCover, is your ultimate go-to expert for group healthcare policies. They are also insurance consultants who can assist you in finding the best group healthcare policy from the leading IRDAI-approved insurance companies. As they offer plans from several companies, they are well aware of the significant features of pan coverage. Connect to the team of PlanCover to discover the right insurance policy that offers maximum support for planned medical treatments and services. 

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