Medical insurance: My insurer only paid Sh1m, what could be the reason?

Understanding your policy’s precise limitations, deductibles, co-payments, exclusions, and lifetime benefit caps will help you manage expectations and make informed decisions about your medical insurance coverage. FILE PHOTO | SHUTTERSTOCK

I have a medical cover of Sh10 million but the insurance company paid only Sh1 million what could be the reason?

Medical insurance is essential for safeguarding our financial well-being in times of medical emergencies. When we diligently pay our premiums and choose a comprehensive coverage plan, it can be disheartening to discover that an insurance company has only reimbursed a fraction of the promised amount.

In this article, I aim to shed light on potential reasons why you might have received only Sh1 million out of the expected Sh10 million from your medical insurance provider. The following factors may contribute to this fact:

Policy limitations

Policy limits could be one cause for the considerable disparity between your projected coverage and the refund.

Insurance policies frequently include coverage restrictions for specific procedures, treatments, or categories of healthcare services.

It’s critical that you review your insurance documentation thoroughly to understand the scope of coverage and any limitations or exclusions.

Deductibles and co-payments

Deductibles and co-payments are standard features of insurance coverage. A deductible is the amount of money you must pay out of pocket before your insurance coverage takes effect.

Co-payments are set sums you must pay for each medical service you receive. If your policy has high deductibles or big co-payments, the total amount reimbursed by the insurance company may be significantly lowered.

Non-covered services

Your insurance policy may not cover some medical treatments, operations, or services. Insurers frequently maintain a list of banned services or treatments, which could explain why reimbursement is lower.

Examine the policy’s terms and conditions to identify any services that may not be covered.

Pre-existing conditions

Pre-existing situations, or medical issues that existed prior to the purchase of the insurance policy, may have an impact on coverage.

Depending on the policy terms, the insurance company may limit or exclude coverage for pre-existing condition treatments, resulting in reduced reimbursements.

Policy lapses, inadequate coverage

In rare situations, policyholders may realise that they had a lapse in coverage or chose an insufficient coverage plan. It is critical to keep ongoing coverage and verify that the policy you select meets your healthcare requirements.

An insufficient policy may not provide the complete coverage expected.

Maximum lifetime benefit

Certain insurance policies have a maximum lifetime benefit cap, which means they will only pay out a certain sum over your lifetime.

If your medical expenses surpass this limit, the insurance will not give extra coverage, which will result in smaller reimbursements.

Billing errors or administrative issues:

Occasionally, payment differences can develop owing to billing errors or administrative difficulties.

It is best to go over the insurance statements and bills you got, double-check the accuracy of the information provided, and call the insurance provider right away if you detect any errors.

When there is a large disparity between the expected and actual medical insurance coverage, it is critical to analyse the possible causes.

Examine your policy terms and conditions, get clarity from your insurance provider, and, if necessary, speak with an insurance specialist or a legal expert.

Understanding your policy’s precise limitations, deductibles, co-payments, exclusions, and lifetime benefit caps will help you manage expectations and make informed decisions about your medical insurance coverage.

Mr Ondiek is a Senior Analyst at Zamara and can be reached via [email protected]