Claim from an excluded provider/hospital
16 Aug, 2021 by Avinash Sonee
Generally in health insurance policies, it is mentioned that
Excluded Providers - Code Excl 11: Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider speciﬁcally excluded by the Insurer and disclosed in its website / notiﬁed to the policyholders are not admissible. However, in case of life threatening situations or following an accident, expenses up to the stage of stabilization are payable but not the complete claim.
Few questions related to the above clause
- Is the list of excluded providers common across all health insurance companies and plans?
- What if the customer or the patient's attender is unaware of this clause or have forgotten about it while getting admitted into the hospital? Is there any consideration given if the emergency admission is proven which is subjective.
- How does a customer prove the life threatening situation? and the stage of stabilization? Does it have to be certified by a third party doctor not affiliated to the said hospital?
- Given the covid situation, can the customer claim that this was the only hospital where he could find a bed? How can this be proved/verified?
- anything else which can lead to claim approval or rejection?