Bolster policy coverage to secure full compensation

PARTIAL PAYOUT OF HOSPITAL BILLS

- KARTHIK JEROME

Insurance Regulatory and Development Authority of India (Irdai) Chairman Ajay Seth recently highlighted a gap in health insurance claim settlement. While most claims are approved, the amounts paid are often lower than customers expect.

“High claim settlement ratios (CSRs) can mask the fact that settled amounts may be much lower than what customers claim. CSR counts approvals but does not reflect the actual amount paid,” says Manju Dhake, head - insurance advisory practice, 1 Finance.

Partial settlements typically result from policy conditions. “Health insurance policies frequently include clauses such as co-payments, room rent caps, sub-limits on treatments, exclusions for certain consumables, and deductibles,” says Saurabh Vijayvergia, founder and chief executive officer, CoverSure. As a result of these policy conditions, customers often have to pay a portion of hospital expenses themselves.

Key reasons for partial payouts