Limitations of Medical Insurance
A Insurance Article Contributed by Deepak Cutting
Limitations of Medical Insurance
The medical insurance company may deny paying for treatment, if they consider that such treatment is not a 'medical necessity'. In many policies, before non-emergency treatment, a 'medical review' must be conducted. A qualified doctor, dentist or other such medical professional must carry out this review. The law lays down the criteria for such a review, when considering approving or rejecting the requested treatment, while allowing for flexibility to cater to the varied circumstances. There is also a dispute resolution mechanism where the unsatisfied customer may appeal.
Approval for treatment is separate from approval for payment and a claim must still be lodged, even if prior approval was obtained for the medical procedure. The insurance company may still refuse to pay for that portion of treatment, which they deem 'unnecessary'.
Pre Existing Conditions and Waiting Periods, As Applied to Medical Insurance
A pre-existing condition is defined as a current medical problem in respect of a policyholder such that was present at the time of acquiring the medical insurance policy. If the policyholder has received medical advice, diagnosis or treatment during the time period of up to 5 years prior to obtaining a medical insurance policy, such condition could qualify to be termed 'pre-existing condition'. Disclosure of the medical condition of the intending policyholder is necessary at the time of negotiating the medical insurance cover. Failure to do so may invalidate the policy.
The insurance company may refuse to cover the policyholder entirely on grounds of pre existing medical condition or may stipulate a waiting period, which may extend to two years in case of individual medical benefit insurance and one year in case of group insurance. Some insurance plans may have a minimum waiting period before any type of benefits can be availed of.
Reducing/Eliminating the Waiting Period
If transferring from one medical insurance company to some other without a break or with a gap not exceeding 63 days, the waiting period can be reduced. However, if the changeover involves the change in type of insurance cover, reduction in waiting period is not possible. Prescribed 'waiting period' covered while under one medical insurance policy can be "carried forward" to the next policy if there in no gap in the insurance cover greater than 63 days.
Long Term Medical Care
This may be defined as that type of medical care or other care services that may arise out of loss of functional capacity or impairment. It is not the same as traditional medical care. Traditional medical care attempts to permanently cure medical problems. Long term care helps the person to live a normal life, to the extent possible, when inflicted with the disability.
Medical insurance plans generally do not provide for long term care. Medical insurance may cover short term nursing but chronic disabilities require specially formulated long term care policy.
The Correct Medical Insurance Policy
If more than one option is available, pick the option having the highest level of coverage within the amount that you can afford. Increase in deductibles will bring down the premium but increase the out-of pocket expenses in case of a claim.
Cost of insurance is not the only consideration. If that was so then why go for medical insurance at all and save the entire cost. The cover offered, financial standing of the insurance company and the claim settlement record of that company are very important.
