Often we hear when someone already has Health Insurance, it turns out when the person is treated for illness, the claim is not paid. This causes insurance is often labeled as a fraud because it does not pay the claim of the person. But on the other hand, we also see, many people whose treatment costs are paid by insurance, even with a value far greater than the cost of care for which the claim was not paid earlier.
Why are there paid, and some who are not paid? Even if paid, it may only be paid in part and some will not be paid. Here we really need to understand the terms and conditions of a claim can be paid. What are those?
Many conditions and conditions for a claim can be paid or not paid, I will try to dissect them one by one. Hopefully with this article, people can understand the terms and conditions of the Health Insurance claim.
#1 Waiting period
There is a waiting period in the health insurance policy, which is a period when the treatment referred to in the waiting period occurs when the waiting period is not over, the maintenance fee will not be guaranteed. This waiting period is calculated from the start of the policy period. The waiting period that is often attached to a health insurance policy is:- A 12-month waiting period for treatment due to certain diseases in which the list is mentioned in the policy. Diseases that usually fall into this category are cancer, tumors, kidney failure, heart attacks, appendicitis, and others.
- The 30-day waiting period for treatment caused by diseases not included in certain diseases.
Whereas for treatment caused by accidents usually are not subject to a waiting period or in other words directly guaranteed since the policy is issued. Some health insurance products also exist that eliminate the waiting period for certain diseases so that all diseases that are guaranteed (not included in the exception) will be valid for 30 days with other diseases. Make sure you know the types of diseases that are subject to a certain waiting period according to the policy.
#2 Exception
Each insurance policy has an exception clause, including health insurance. This clause explains what conditions are not guaranteed in the policy. Some examples of exceptions are: suicide, war, natural disasters, drug abuse, conditions that have existed from birth (congenital), pregnancy, cosmetic surgery, costs that do not include medical action, AIDS / HIV, alternative medicine, and etc.#3 Needed Medically
Some actions in the hospital by doctors sometimes there are those that are not actually needed medically, usually due to requests from patients or families of patients. The cost of treatment that can be guaranteed must be consistent with diagnoses and medical treatments that are in accordance with the usual medical practices for handling accidents or illnesses. One example is the actual inpatient request by the patient. This action can be carried out by outpatient care only.#4 Replacement Limits
Not all maintenance costs can be replaced by the health insurance you have. This type of action is limited by certain limits. For example for surgery costs at a limit of 50 million per surgery, doctor's visit costs 150 thousand per day, and limits of other actions. For this you need to look at the benefit table according to the Plan choices you have. Some other health insurance products also do not limit the cost per action. For these products, the limit is usually limited from the total claim within 1 year, and is limited to the maximum tariff or room class.#5 Guarantee Type
The type of guarantee that is popular is the guarantee of hospitalization, which means that the cost of care guaranteed is only if the patient is hospitalized with a minimum number of hours (usually between 6-24 hours). Usually hospitalization guarantees are accompanied by a limited outpatient guarantee, which is usually an outpatient guarantee that occurs within a few days before hospitalization, and also outpatient care as a follow-up treatment after inpatient treatment which is usually a maximum of 30-90 days after hospitalization stay in. Other types of collateral available are guarantee for outpatient care, pregnancy / childbirth care, dental care and glasses. These guarantees are usually more popular for corporate customers because of the higher risk.#6 Pre Existing Condition
That is a condition that already exists on the insured before the insurance period begins. This condition is usually no longer guaranteed by insurance companies. So that when treatment due to these conditions occurs within the period of insurance coverage, the costs cannot be paid. Unless the insurance company has agreed to the condition from the beginning on the basis of the prospective insured's information regarding his medical history.#7 Guarantee Area
There are provisions where care can be taken. Indonesia, Asia, or the whole world, or with the exception of certain countries. So that if you are treated in the area, insurance will not guarantee collateral payments. But some insurance provides provisions for guarantees outside the guaranteed area, provided that the treatment is caused by an emergency condition, for example an accident while traveling.#8 Incomplete Claim Documents
Actually it does not mean that the claim is rejected, but the claim will be suspended, until the required document can be provided by the person who filed the claim. In filing health insurance claims that are carried out in a reimbursed manner, the required documents are:- Claim form (original) provided by the insurance company that is filled by the doctor who handles it;
- Receipts (original) along with details of fees from hospitals or clinics;
- Copy of prescription in the case that medicines are purchased outside the hospital or clinic. A copy of the recipe is written behind the receipt for the purchase of medicines;
- Documents supporting maintenance, for example the results of laboratory and medical records;
- The identity of the insured and the policy holder, along with the copy of the account book as the purpose of claim payments by the company.