Health Insurance Claim: Health insurance claims can often be rejected due to the reasonable and customary clause. Insurance companies will only pay expenses they deem reasonable, which can increase patient expenses…
Health Insurance Claim Rejection: I have a mediclaim. The insurance company will cover all my hospital expenses… If you’re thinking the same, then wait a moment. Health insurance policies contain many clauses that can jeopardize your claim. Today, we’ll tell you about one such clause, which is crucial for you to keep in mind.
Most people assume their health insurance claim will be easily approved upon hospitalization. However, the Reasonable and Customary Clause, hidden within the policy, often results in the claim being rejected even after treatment.
What is the Reasonable and Customary Clause?
This clause gives insurance companies the right to pay only those expenses they deem reasonable and normal. Simply put, the insurance company can question the cost of treatment and the length of hospital stay. This can increase the patient’s expenses.
To illustrate, a driver was admitted for treatment of gastroenteritis. After treatment, a bill of ₹25,000 was received, but the insurance company can reject it. Under the Reasonable and Customary Clause, they can reject the bill, stating that this treatment did not require hospitalization.
Also, if a patient is scheduled to undergo coronary artery surgery, which costs ₹5 lakh, but the patient claims ₹15 lakh, the insurance company can reject it.
How to avoid claim rejection?
- Get complete information before treatment.
- Understand hospital prices and protocols.
- Seek a second opinion.
- Keep the discharge summary and medical justification clear.
- Follow the advice of an experienced doctor.
- It is best to seek treatment at hospitals within the insurance company’s network.
