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Most claim disputes arise from three things patients did not know about their own policy. Reading these sections before you need them saves a great deal of difficulty later.
Waiting periods
- Initial waiting period: usually 30 days from policy start, during which only accident claims are payable
- Pre-existing disease waiting period: typically two to four years for conditions you had before buying the policy
- Specific ailment waiting period: often one to two years for cataract, hernia, piles, joint replacement, hysterectomy and similar conditions
- Maternity waiting period: commonly two to four years where covered at all
Worth knowing
Never conceal a pre-existing condition when buying a policy. Non-disclosure is the single most common ground for claim rejection, and it can invalidate the policy entirely at the moment you need it.
Cashless versus reimbursement
Cashless treatment works only at hospitals in your insurer's network. Pre-authorisation must be requested at or before admission, and approval is granted for a specified sum which may need enhancement if the stay extends. Non-medical items are not included and are settled by you at discharge.
Reimbursement applies when you are treated outside the network or when cashless is declined. You pay first and claim afterwards, submitting original bills, the discharge summary, investigation reports, prescriptions and the claim form, usually within fifteen to thirty days of discharge. Keep photocopies of everything you submit.
Commonly excluded items
- Registration, admission and service charges
- Attendant food, telephone, television and toiletries
- Gloves, masks, sanitiser and many disposables, depending on the policy
- Cosmetic procedures and dental treatment unless resulting from accident
- Health check-ups and screening
- Spectacles, contact lenses and hearing aids in most policies
- Treatment abroad, and injuries from adventure sports, in many policies
Terms worth understanding before you need them
Room rent limit is the most commonly overlooked clause. If your policy caps room rent at 1% of sum insured per day and you take a more expensive room, many insurers apply proportionate deduction — reducing every associated charge, including doctor fees and procedures, by the same proportion. A small room upgrade can therefore reduce the whole claim substantially.
Co-payment means you bear a fixed percentage of every claim, often applied in senior citizen policies. Sub-limits cap the payable amount for specific procedures such as cataract or joint replacement regardless of actual cost. A deductible is an amount you pay before cover starts.
Reducing the chance of rejection
- Declare all pre-existing conditions honestly at purchase
- Inform the insurance desk at admission, not afterwards
- Ensure the diagnosis and treatment are clearly documented in the discharge summary
- Submit claims within the stated time limit
- Keep all original bills, prescriptions and reports
- Confirm that day-care procedures under 24 hours are covered — many now are
- Renew on time; a lapse resets your waiting periods
Key takeaways
- Never conceal pre-existing conditions — non-disclosure is the leading cause of claim rejection.
- Room rent limits can proportionately reduce your entire claim, not just the room charge.
- Inform the insurance desk at admission; cashless cannot be applied retrospectively.
A note on medical advice
This article is general health education written and reviewed by the Patient Care Services at SIMS. It is not a substitute for an examination, a diagnosis or the advice of your own treating doctor, and it cannot account for your history, medicines or reports. If a symptom is sudden or severe — chest pain, stroke symptoms, breathing difficulty, serious injury, seizures or heavy bleeding — call 9281862028 or come straight to the emergency department instead of reading further.
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