Will I Get Money Back From Health Insurance?

When getting an insurance policy, there are various things to keep in mind. One of the questions that seem to pop up often in people’s minds is,

“Will I get money back from health insurance?”

The answer is simple. Yes.

But it also depends on the type of insurance policy you have or want to purchase. That’s what we will explore in detail.

How to Get Money Back From Health Insurance?

Is it possible to get money back from health insurance? Yes, thanks to the Affordable Care Act which says insurers must spend 80 percent of the amount they collect for medical claims and initiatives such as wellness programs. If an insurer spends less than the 80 percent set out, they will have to give you a refund.

Insurers were recorded to owe a whooping $743 million in 2018 to 2.7 million individual policyholders which was four times what they paid in 2017.

The recorded amount is so large because of the insurers putting steep premium increases on the policies in 2018 so they could cover their uncertain costs. They ended up being able to pay less than 80 percent of it and thus, owed many people a refund. “Insurers were pretty nervous about setting premiums without knowing the rules of the game, so they priced cautiously, which meant pricing high,” vise president at the Kaiser Family Foundation, Cynthia Cox says.

Refunds also vary state by state. Some places offer better refunds and some don’t. It depends on where you live which is why it is encouraged to research and speak with an insurance agent before getting an insurance policy so your agent can help you file a claim if need be.

How to Get a Refund?

You can request a refund by submitting a health insurance claim. But before you do that, it’s important to know if you’re already owed money. Here are a few ways you can check that.

  • Keep an eye on your mail.

It is important to keep a lookout for any mail from your insurer. It is likely that they notify you of the refund through mail. It could either come in a lump sum amount or through installments. If for some reason you think insurers might not be able to reach you through mail, be patient. Insurers are required to make a good faith effort to contact you to pay the refund. If your email is somehow inaccessible, they will contact you through some other medium.

  • Call your insurer.

If your insurer has not contacted you themselves, give them a call to see the status of your refund. It is possible that you might have missed a notification. Keep yourself prepared with all the details of your plan in case they have any questions.

  • Contact the state.

If your insurer is unable to find you, they are obligated to hand over the refund money to the state as abandoned property. It can take a while for the insurer to hand it over to the state but that depends on state regulations. You can check at missingmoney.com, a database by the National Association of Unclaimed Property Administrators.

If you aren’t qualified for a refund, you can choose to file an insurance claim if you have health insurance. To determine how you can file a claim, it is essential to find out what kind of health insurance coverage you have.

Types of Insurance Coverage

There are essentially two types of coverage for health insurance:

1.   Indemnity.

In this plan, as per the terms and conditions of the policy, you can claim reimbursement of the actual expenses incurred as compared to the amount insured for specified illnesses.

2.   Defined benefit plans.

In the defined benefit plans, you are insured for any pre-agreed illnesses. You will get the amount that was insured if you contract any of these illnesses.

The difference between the two policies is that, in the defined benefit plan, the payment of sum insured is dependent on you contracting the illness rather than any expenditures incurred as it was in the indemnity policy.

How to Submit a Health Insurance Claim?

A health insurance claim can be submitted through two means:

  1. Whenever you buy health insurance, your insurance provider will give you a list of hospitals that they cover as part of their network. If you go to any of these hospitals, you can use your insurance e-card and continue to be hospitalised without paying any cash. These are the cashless benefits provided by your insurance company.
  2. The second way an indemnity claim is paid is through reimbursement of expenses. You can pay for all your expenses upfront and get a bill that can then be submitted to your insurer who will reimburse your expenses. This reimbursement feature can come into handy if you have been submitted to a non affiliated hospital in the case of an emergency.

Is There a Time Limit to Submit Health Insurance Claim?

Most health insurance policies require a patient to be submitted for over 24 hours before a claim can be submitted. All the procedures for the benefits would be detailed in your policy agreement. You will not be able to submit any claims if your policy has lapsed.

Although it might be tedious for you to go over the entire policy agreement, it is extremely important that you do so. You can then find out if there’s a time limit, claim amount limit, room rent caps or waiting periods for certain illnesses. It is not uncommon for health insurances to have a waiting period for certain diseases. This can cause a strain on the time limit and you might not be able to claim your insurance as soon as you had hoped.

How Health Insurance Claims Get Paid

If a hospital is on an insurance network, it is bound to have an insurance desk set up. All you need to do is fill out a pre-approval form for planned hospitalisation. If it’s an emergency hospitalisation, intimation can be done within 24 hours. The only thing that is required for cashless benefits is the insured’s identity proof along with the health card.

It is advised to communicate with your hospital about your policy coverage details right from the start so they can better assist you. In case of your policy coverage running out, the hospital staff can inform you beforehand.

For reimbursement claims, it is important to have an insurance claim form filled out along with the doctor’s reports, diagnosis and admission reports. All the bills should also be stamped and signed properly. A crucial document needed for a reimbursement claim is the discharge summary that you need to provide with your claim. All original documents must be provided although it would be helpful to keep copies with you.

Once your insurer has viewed and accepted the claims, they will transfer the amount to the account you have provided. Thus, it is important to double check all the details before submitting the form.

Although not all insurance types have money back guarantee, with money back health insurance, you can claim your amount. And in case the amount you are claiming is not the 80 percent for the sum insured, health insurance companies are obligated to give you a refund. So when it comes to the question, “will I get money back from health insurance?” The answer is yes.

Nabeel Ahmad

Nabeel Ahmad

Nabeel Ahmad is the founder and editor-in-chief of Insurance Noon. Apart from Insurance Noon, he is a serial entrepreneur, and has founded multiple successful companies in different industries.

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