Is depending on a group health insurance policy good enough?

Smartchoice Editorial
October 10, 2021

Well to get an answer to this situation, let’s talk about a situation

You are on a school picnic at an amusement park. You are not carrying lunch with you, as you were informed that your school will provide you with sandwiches. You think it will be enough, and since you were promised you didn’t give it a second thought to carrying something of your own, you do not carry any pocket money with you. But your hunger doesn’t go with the sandwiches served. If only you had carried some money along, you could have bought something for yourself to eat.

Have you ever heard the term “covering all fronts”, well while living in Pakistan and being middle-class individuals or professionals, we are constantly worried about even the smallest thing? We try to cover everything and anything that can be a sign of any pertaining worrisome thing. We tend to buy covers for anything we might feel that would provide us with a financial cushion and emotional peace.
Many companies are providing health benefits considering a number of benefits to retain employees, loyalty and increasing productivity. Keeping that in view many employers offer this benefit but sadly this benefit ends once an employee leaves the job and the workplace. One needs to have a sound health plan for its self and their families.

One question that many people have and it’s usually one of the things that matters the most is is it possible for an individual to have more than one health plan to cover the medical expenses that may arise.
When someone talks to us and tells us about investments and finances, we have our answers ready! We have done our research on what is best for us and how to select the right avenues, all done and prepared. But when it comes to choosing the best health insurance plans for family or yourself, to protect your savings and someone questions us on it, often our answer is “Why do I need one? My company covers and provides me with the needed of me and my family under their corporate health insurance policy.

Most of us can relate to this situation of having a corporate health insurance plan. And you might give it a thought on what’s wrong with it? Well, in principle, nothing. However, the essential question that remains unanswered is “Is it enough to cover your family’s health or do they need another health insurance policy?”. And that is exactly what we will be speaking about here in this article, in our simplification drive.
A corporate health insurance policy is definitely a great health benefit. Why? Simply because it offers a certain level of protection and coverage for you and your family, at the expense of your employer 😀 (happiness indeed ) and the company makes sure that this added benefit of an employer’s health insurance, will lead to better retention in the company and create loyalty.

But, the problem with depending on only a corporate health insurance plan.

Firstly, the business’s health insurance policy has a standardized Sum Insured for all employees and their families.
However, your needs and requirements might differ from the other workers. The right Sum Insured should ideally be based on your age, life stage, family arrangement, lifestyle, medical history, etc. Depending on your and your family’s requirements, a standard employer’s health insurance policy may not protect the employee completely when they actually need it.

Suppose, your Sum Insured is 2 lakhs and unfortunately, you face a sickness that necessitates hospitalization and the bill comes up to 3 lakhs. The extra 1 lakh after your employer health insurance claim to be paid, has to be borne by the employee if they don’t have an additional individual health insurance policy.

Now, you might have your savings to rely upon. But in case (God forbid), someone in your family suffers from a Life-threatening Illness and the treatment cost shoots up to more than 10 lakhs, can you still rely on your savings? And even if you can, exhausting all your savings leaves you money-wise unprotected for the future, esp. in a time which is otherwise also very mentally straining.

Secondly, an employer’s health insurance policy is applied and available till you are employed. When you leave your job or tend to switch it, the corporate health insurance cover ceases to exist immediately. So, the time when you are in between jobs or on a time off, you are basically without any health insurance policy. If anything ill-fated does happen during this period, you are left completely unprotected and vulnerable.

And the most imperative purpose is your family. Though some corporate health insurance policies cover your dependents in your plan but again that coverage which ranges from PKR2 lacs to PKR5 lacs is not enough. And given the healthcare conditions, coupled with inflation is 20% as compared to 8% overall, it is important to evaluate your health insurance protection.

So, what is the solution?

Simple, procure a personal health insurance plan parallels with the right Sum Insured that fits all your needs, so even if your corporate health insurance plan cannot cover your health expenses completely, you always have your individual health insurance policy to make an insurance claim with. And if 2 health insurance policies are becoming a pain to maintain, stick to your corporate health insurance plan and take a top-up plan on it. This way, even insurance claims needs that are over and above your corporate plan, are taken care of.

Note- In case you leave your job, the amount of coverage that was borne by your employer earlier will have to be paid from your pocket since you would lose the cushion of coverage provided by the employer.

Let us clarify this with an example

Suppose, Rasheed has corporate health insurance of PKR2 lakhs. He takes a personal health insurance plan of PKR5 lakhs, making the total Sum Insured as PKR7 lakhs. Now, he had to leave the job due to a particular reason and regrettably, has to be hospitalized for treatment, and the bill comes to PKR7 lakhs. As he also has his personal health insurance plan, at the time of claims, it will only come into action after the company pays the initial PKR2 lakhs. Given that the employer is no longer responsible for Rasheed’s health insurance claim, that amount will have to be paid by Rasheed himself, as an added amount that is above his personal health insurance coverage limit.

Can We Claim Health Insurance from Two Companies?

One reason to buy additional health insurance could be that one has availed of additional coverage over and above the group insurance offered by the company. Alternatively, that the employer might offer an old policy that means with limited coverages and to procure higher coverage one might choose a second insurance plan for better coverage. A third reason may be that an individual has two policies; one that covers your parents and the other covering their spouse and children.
The procurement of policies and coverage entirely depends on the need of the family, the number of family members and the kind of coverage desired (meaning the frills that you may need to get covered).

The process to make multiple claims

The important part is to know, understand and learn the steps involved to get the claim, if an individual understands the do’s and don’ts beforehand one can easily get the claim without further hassles and delays.
the Insurance Regulatory and Development body in Pakistan security exchange commission Pakistan has been making and proposing changes in the framework and regulations to serve people better.

The modifications have made the procedure easier and simpler. Now, if the claim amount is less than the sum assured, the insurance provider will provide the claim without any hick-ups or issues. However, for claims exceeding the sum assured, the insurance provider might add some terms and conditions but, you may choose the insurance company from whom you want to make the first claim.

1. Cashless claims

For such cashless claims, you make the claim from one insurance company and procure the settlement summary from that provider. On completion, you will need appropriate copies of all the bills. If the bills exceed the sum assured by one insurance provider an individual may then approach the second company for claiming compensation of the balance amount from the other provider.

2. Reimbursement claims

Cashless claims are appropriate because the insurance providers settle the hospital bills directly with the hospital. Nonetheless, there are some hospitals that do not follow such procedures means they might not be on the panel of the network hospitals of the insurance provider. In this situation, the individual needs to first pay the amount from their own pockets and then follow the HEALTH INSURANCE CLAIM PROCESS designed by the insurance provider for compensation. The policyholders need to submit all original documents (that are retained by the insurance provider) along with the claim application form.

Documents needed to make reimbursement claims

When you plan to make claims under multiple health insurance policies, the individual must intimate and initiate requests with all the insurance companies at the time of hospitalization. After this, the policyholder may choose the company from where they wish to make the first claim. Here is the list of original documents that must be attached with the claims form.

1. Bills and receipts
2. Discharge forms
3. Diagnostic tests
4. Prescriptions
5. Films and slides, if any required or undertaken at the time of diagnosis or treatment

When you make a HEALTH INSURANCE CLAIM, it is recommended you choose your employer’s insurer as the process will be quicker. It is important you procure multiple attested copies of the aforementioned documents from the hospital. The first company will provide a claim settlement summary, which must be submitted to the next insurer to file the claim for the balance amount.
There is always a possibility that your health insurance claim is denied (due to any reason). This may happen because the policyholder did not inform the insurance provider about existing policies at the time of buying the plan. Alternatively, the claim may exceed the amount assured as per each individual. Having adequate health coverage is fundamental as medical expenses are constantly rising. However, it is worthwhile to obtain higher coverage under a single plan instead of purchasing a smaller sum assured under multiple policies.

How to claim health insurance from your employer?

In Pakistan, amid the pandemic, many companies have given out suitable group health insurance policies for their personnel. While most companies cover employees under group health insurance, there are a few formalities and profiles to be completed before the insurance starts working. If not filled in time or in the approved manner, the employer may not pay the claim if and when needed. Hence, to make things easier, policyholders must follow these four steps before filing for a group health insurance claim.

1. Update the family’s profile: The first thing an employee should do after receiving their employee ID or confirmation letter is to update your family’s information on the company’s portal. According to a head- corporate business, of an insurance integrated platform, said, “You will not make claims if you have not entered the necessary information into the insurance portal. Prioritise this step.”
2. Get an E-card or Health insurance card: The employer will give you a third-party administrator (TPA) for instance TPL, Jubilee or IGI whoever insurance your employer procures. A card once your health insurance policy is issued. If you intend to use a cashless facility at a hospital, this card will come in handy. Also, remember to bring the employer’s E-card because if it is misplaced or forgotten the physical copy of your TPA card while in the hospital, one can always submit the e-card. It is also pertinent to mention that it is also a must to submit an ID proof in addition to the E-card.
3. Understand the benefits offered in the plan: Always read the policy document carefully and exhaustively when purchasing any policy, not just health, but the car, travel or life insurance. To avoid last-minute complications, one should first learn what is covered and what is not. “Corporate health insurance policies frequently include restrictions, such as the number of family members covered, different exclusions and room-rent limitations,” said HR Head of a reputed firm.
4. List of network hospitals: By and large, insurance companies have an agreement with a selected group of hospitals (the larger the better) to provide cashless services to their customers. These hospitals are referred to as on-panel network hospitals. While going through the policy document, make a list of these hospitals.

How to file a claim

The policyholder should try to get treatment in a network hospital of the insurance provider. At the same time, the policyholder family members should provide details of the health insurance policy and the policy card to the hospital.
An expert of corporate health insurance believes that “the Policyholder family should be well-versed in the provided employee’s healthcare policy. Keep them up to date on all of the lists that have been created and keep the policy documents in an easily accessible location.”
Usually what happens is once you get discharged from a network hospital, all expenses related to medical bills are sent to the insurance provider by the hospital. The insurance provider then evaluates the costs and gets the claim settled with the due course of action.
A corporate health expert said, “In the case of company insurance, the employee should inform the dedicated department of the organization who can help in the claim process, approval and settlement altogether.”

4 Reasons Why the Health Insurance Claim could be rejected

Many of us have the habit of not paying attention to the fine print of a health insurance policy. This mostly happens due to a lack of seriousness and awareness of the consequences. The carelessness towards health insurance can be one of the main reasons the claim is rejected. This might sound less severe for those who don’t really understand the gravity of the situation. However, the people, whose claims have been denied, would find the experience quite exhaustive and retributive.
So, it is fundamental to know the reasons for which a claim can be overruled. At the same time, it is also important to understand the precautionary measures one needs to undertake. There is a popular saying that “prevention is better than cure”. Similarly, in the insurance segment, it is better to avoid rejection than taking corrective measures later on.

An insurance company can divert your claim after rejection, provided that the policyholder is able to convince the insurance provider that the claim initiated is genuine. However, the policyholder first needs to know why it was forbidden and then take corrective measures. There are many reasons for denying your claim. These could be due to getting admitted to a non-network hospital, ignoring exclusions and putting forward them to the insurance providers, etc. So, let us elaborate on the 4 reasons because of which your claim can be rejected.

1. Going beyond the Sum Insured
Have you heard about a thing called Sum Insured? When you decide on a health insurance policy or a personal accident policy, there is a pre-determined “sum-insured” involved whether it is a family floater or an individual health cover. Depending upon the chosen plan and the required monetary coverage, the sum insured is the amount available to the policyholder and their family on annual basis. Presuming that you have consumed the entire sum for a particular year, the successive cashless claims will get rejected. However, if a part of your sum assured is still integral, the insurance provider might provide the policyholder with reimbursement at a later stage.

2. Ignoring the exclusions
There are several diseases, illnesses and sicknesses for which coverage is not there in most of the health insurance plans. These are specifically and explicitly mentioned in the policies as being ‘not covered’. These are fundamentally diseases for which you can’t file a claim and are generally referred to as exclusions of the policy. However, if certain plans or policies provide coverage for any such disease, then a waiting period will be there for the same. So, if you file a cashless claim for one such disease/medical condition that is excluded, then rejection is understandable.

3. Suppression, misrepresentation of facts
Some common causes for claims being overruled are non-disclosures, partial disclosures and wrong disclosures of significant and essential details such as age, nature of occupation, income, current insurance plans, major ailments or pre-existing medical conditions. Coverage is provided on the basis of the data given by the nominator on the proposal form, so any inconsistency between the declaration and the reality during the time of filing claims can easily lead to the refusal of the claim. The only solution to this problem is to be quick and precise while filling forms.

4. Exceeding the time limit
In a health insurance policy, the individuals are required to apply for compensation within a certain time frame. As for emergency admission, the time allotted is 24 hours after the patient has been admitted, and in other cases, it can change according to the type of policy the policyholder has opted for and the treatment being availed by the policyholder. If the policyholder doesn’t apply within the time indicated, the claim can be rejected.

So, if you take our advice, don’t just depend on your corporate health insurance plan. The wise thing to do is to take a personal health insurance plan so that you are never under-insured or left without health insurance.

After all, this is about the most important aspect of life: your well-being.

It can be easily established that in order to avoid cashless claim rejection, one should possess a good understanding of your health insurance policy, ideally from the time when making the purchase. Then, you need to compare health insurance plans online to understand what is on offer, comparing with what you need and then choose a policy that best meets your requirements. It is also appropriate to maintain a record of all your documents.pre and post hospitalization expenses, hospitalization records, diagnostic tests, discharge summary, investigation reports, etc. These documents can be extremely vital if your insurer needs clarifications.

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