In the face of unexpected health challenges, health insurance can either emerge as a dependable ‘knight in shining armour’ or a ‘complex labyrinth to navigate’.
Regrettably, in the aftermath of an emergency, individuals often develop a less favourable perception of both insurance and insurers. This perception primarily stems from a lack of understanding of the fundamental concepts related to health insurance and its processes at the time of an emergency.
Hence to ensure a seamless experience, it is crucial to grasp a few basic concepts before any unforeseen health emergency arises. This holds true even in the realm of employer-provided group health insurance, where the involvement of employees in determining coverage terms is generally limited. Taking proactive steps to familiarise yourself with key terms is the first stride toward preparing for any potential medical emergency.
Cashless claims
A cashless claim means that the insurance company directly pays the hospital based on your policy terms with the hospital.
Network hospitals
Network hospitals, also referred to as network providers or cashless hospitals, are healthcare establishments that have entered into an arrangement with your insurer. This arrangement enables you to avail cashless services at these network hospitals. The list of network hospitals undergoes periodic updates and can be conveniently accessed on the insurer’s website or through toll-free numbers provided on your health card or insurance documents.
Non-network hospitals
Non-network hospitals do not have any pre-established arrangement with the insurer. In the case of non-network hospitals, you are required to pay the incurred expenses directly from your pocket and subsequently submit a claim to the insurer.
Blacklisted hospitals
As the name implies, blacklisted hospitals are those deemed ineligible for coverage by an insurer. It is essential to check the list of ‘Blacklisted Hospitals/Non-Preferred Hospitals/Caution Hospitals’ where insurers do not entertain cashless or reimbursement claims—except in some instances of emergency admissions.
Why should you opt for network hospitals?
Choosing a hospital that is a part of the network list of the insurer can significantly impact your healthcare experience and maximise the utilisation of policy benefits during adverse conditions.
Cashless facility: Alleviates the burden of arranging funds for treatment, especially in case of emergencies.
Hassle-free: Eliminates paperwork involved in reimbursement of claims.
However, to avoid last-minute surprises, you need to further consider the following factors related to network hospitals:
Sum insured: Keep track of your maximum coverage limit under the policy.
Room rent limit: Be aware of room rent limits, as exceeding them may lead to deductions by the insurance provider.
Sub-limits: Certain ailments may have defined sub-limits; pay attention to these restrictions.
Co-pay: Check if your policy has a co-pay requirement, where you bear a fixed amount or percentage of the medical bill.
Deductibles: Understand any defined amount to be borne by you before filing a claim to the insurer.
Non-payables: Some consumables and items in the hospital bill may not be covered; be prepared to bear these costs.
In the case of planned medical procedures, one typically has time to familiarize with the hospital network provided by the insurer. However, this may not be possible during a medical emergency. Navigating between medical procedures and protocols, etc., can leave anyone frazzled. Therefore, it is advisable to identify nearby hospitals and note their classification (network or blacklisted) at the time of policy purchase.
Keeping this information up to date through regular reviews or at the time of policy renewals, ensures better preparedness for any unforeseen medical emergencies. Preparing ahead of time may not only ensure comprehensive coverage and optimal utilization of health insurance benefits but it may also make a significant difference in receiving prompt and effective medical care.
Rajive Kumaraswami, MD & CEO at Magma HDI General Insurance
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Published: 07 Jan 2024, 11:40 AM IST