When you submit a claim under a hospital bill, the insurance company will apply the following deductions on the amount that you have spent for medical treatment:
a) Pre-existing illness. You are usually not covered for medical conditions that exist before you purchase the insurance, including congential conditions.
b) Exclusion. Certain medical conditions are specifically excluded, e.g. HIV, self-inflicted injuries.
c) Sub-limit. You are allowed to claim up to a liit for each item, such as daily room and board, hospital expenses and surgery. Any expense above the sub-limit will not be claimable
d) Pro-ration. If you are insured for a lower class of ward, and you are treated in a higher class of ward, a pro-rated formula may apply. Only this pro-rated portion of the expenses will be counted.
e) Deductible. This is the amount that you have to bear first, before you can make a claim for the excess of the eligible bill.
f) Co-insurance. You have to pay a percentage of the eligible bill in excess of the deductible.
When you submit your hospital bill, the insurance company will apply the sub-limits, exclusions and pro-ration to get the eligible amount. It will then apply the deductible and co-insurance to determine the final amount that is payable.
Before you incur a large bill, it is advisable to get an estimate of the hospital bill from your doctor and to check with your insurance company on what proportion of the bill is payable under the insurance policy.
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