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We often read or hear about health claims being rejected by insurers on flimsy grounds. Sometimes, however, the insured is also to be blamed simply Reviving lapsed insurance policy going for householder's insurance because he/she is found to have made false declarations while taking the policy or failed to go through the fine print before buying one.

True, health covers are bought with a view to taking cover against any financial constraint that may arise because of a medical emergency, and insurance companies are bound to honour legitimate claims within policy limits. At the same time, however, it must be understood that insurance companies are not charitable organisations. Therefore, they can't be expected to honour a claim if the claim is not made in accordance with agreed terms or if a particular disease is listed under the policy exclusions.

The repudiation of a claim may be due to many reasons such as loss falling beyond the scope of policy coverage, exclusions under policy, or breach of conditions or warranties, among others.Generally, however, "the primary reason for an insurer rejecting a claim is that a particular disease is listed under the policy exclusions and consequently cannot be covered.

Therefore, only getting a health cover is not enough. It is equally important to read and understand the terms and conditions of a policy well and be clear about the policy you plan to take in order to avoid any hassle or heartburn in the future. It would also help if one knows how to make a claim and what to do in case something goes wrong.

While buying a health policy, the customer is required to opt for either cashless or reimbursement mode of settlement. In both the cases, however, it is important to understand the claim procedure lay down by the insurers.Simply because at the time of emergency, the understanding of the right procedure can help reduce unwarranted panic.

Insurers have tie-ups with a network of hospitals across the country. If the customer opts for cashless claims, he/she has the facility of cashless treatment at the networked hospitals. This list of the network is generally available in the policy kit and also on the website of the insurers.

"In case of emergency hospitalisation and admission, the TPA (third party administrator) needs to be intimated through a toll-free number within 24 hours. In case of a planned admission, however, the TPA is to be informed three days in advance. Also, the insured must remember to quote his/her health card membership number and/or policy number," says Bimbhet.

While getting admission, the cashless request form available with the hospital insurance help desk is to be filled and certified by the doctor.Having done that the form with supporting medical records is to be faxed by the hospital to the TPA's fax number.