Health Insurance is easy to buy and it is the most essential insurance cover one should buy. Before buying health cover, one should know the technicalities of how the coverage works and under what types of scenario, you can apply for a claim. So what happens if hospitalisation continues beyond health insurance last date?
In case the hospitalisation continues beyond health insurance last date, the following procedure will be applicable depending upon the limit of sum insured:
If the limit of sum insured is not exhausted: The sum insured of the current policy can be used to pay the hospitalization that started during the policy period and continued beyond the last date.
If the limit of sum insured is exhausted: If the sum insured is used up then the renewed insurance’s sum insured amount cannot be used for this same hospitalization.
In a nutshell, one can claim the amount up to the limit of sum insured within the term period of the health insurance policy. This policy covers the hospitalization started within the policy tenure, up to the remaining limit of sum insured. The insured cannot use the sum insured of the next year policy tenure in case of continued hospitalization.
The mediclaim policy does not cover medical cost exceeding the amount of sum insured during the tenure.
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Case Study 1: A claim paid despite extending beyond the last date
Rohan bought a health insurance plan on 1 January 2014. The amount of the sum insured was 5 lacs. From 2015 to 2017, Rohan renewed his medical insurance policy timely with the same insurer. In 2017, all the waiting period has been exhausted and he was eligible to claim for pre-existing and specific diseases.
In 2017, Rohit suffered from a heart attack. Rohan was admitted to hospital and intimated the claim to the insurer on December 26, 2017. His treatment continued till 3 January 2018. The cost of treatment was Rs 4.5 lakh.
In such case, Rohan will receive the full amount covered under the terms of policy. This is because he had not exhausted the limit of sum insured within the tenure of the policy. Also, this was his first claim in that year and the cost of treatment was within the limit of sum insured.
Case Study 2: A claim rejected despite extending beyond the last date
Kamal has a health insurance plan starting from 1 January 2015. The health insurance policy is still active. The sum insured amount is 3 lakh. In 2017, Kamal faced a major medical issue which caused a claim of 2.5 lakh.
Later, in the year, he faced another medical emergency on 29 December 2017 which cost him Rs1 lakh. In this case, Kamal received the coverage of Rs 50,000 only. The limit of sum insured is 3 lakh and in the first claim he had already used the limit up to 2.5 lakh. Therefore, in the next claim, the limit of indemnity for the year left was 50,000. The policy will not reimburse the amount from the renewed sum insured.
In this case, if Kamal could have used the full sum insured limit in the first claim only, he would not be eligible to claim for the next medical emergency during the tenure of the policy. The limit of sum insured plays a pivotal role in claim settlement. In any case, the insured will only get coverage up to the limit of sum insured during hospitalization.