If you stay in deluxe room doctor charges and other charges are higher
as long as your total bill is less than Rs 8 lakhs insurance company would settle your bill in full
you can stay in 10 k room if as per your policy you are entitled to said room
Claim settlement - based on room rent
I’m planning to get Niva Health Insurance (Sum Assured ₹10,00,000) for my father who is 70 and having existing medical conditions. I am aware that for first 24 months anything arising from existing medical conditions is not covered. Lets say there are four room category in any hospital, General Sharing Room ₹3,000 per day Deluxe Accommodation for only patient ₹5,000 per day Semi Special Accommodation for patient with one family member ₹10,000 per day Special Accommodation for patient with one family member ₹12,000 per day Suite Accommodation for patient with one family member ₹15,000 per day However, after 24 months, if he needs to be hospitalized for any illness and if the bill is around 8 lakhs. Will there be a difference in claim settlement if he is staying in Deluxe room or semi special room? Will there be room rent limit apply in this case since I am opting for ₹10,000 instead of ₹5,000 (Single Private Room - as stated in policy wordings)? In Policy Wordings it is stated that, Single Private Room means an air conditioned room in a Hospital where a single patient is accommodated and which has an attached toilet (lavatory and bath). Such room type shall be the most basic and the most economical of all accommodations available as a single occupancy room in that Hospital.
Asked 1 year ago in Consumer Law
6 Answers
In Policy Wordings it is stated that, Single Private Room means an air conditioned room in a Hospital where a single patient is accommodated and which has an attached toilet (lavatory and bath). Such room type shall be the most basic and the most economical of all accommodations available as a single occupancy room in that Hospital. This to my understanding is Deluxe Room - 5,000 per day.
Asked 1 year ago
Stay in deluxe room if you are allowed as per policy
check with your insurance agent
the policy would contain a clause as to room capping charges
No the amount which is the highest cap will be considered as per your policy
The descriptions what you have stated may or may not accommodate the policy coverage.
For more clarity you may have to refer to the policy conditions printed on the policy .
The insurance adviser or the staff of the insurance company will not give you correct picture, they may exaggerate and assure additional facilities which is non existing and when you go for a claim you will be disappointed, hence you may always refer to the conditions and the terms mentioned in the policy.
It depends on the hospital that what type of rooms available with them and as per the choice of the patients.
Your understanding may be right or wrong and it will stand clarified only when you with a claim because our interpretations will not be entertained by the insurance company when a claim is raised.
They will explain their own interpretations of the terms printed in the policy.
The above opinion is based on the practicality of the events that takes place after selling the health insurance policy by the insurance company
Dear client,
In health insurance policies, especially concerning pre-existing conditions, there's often a waiting period before coverage kicks in for those specific conditions. You've mentioned that your father's existing medical conditions won't be covered for the first 24 months, which is a standard practice in many health insurance policies.
Regarding the room category, after the waiting period of 24 months, if your father requires hospitalization and the bill amounts to around 8 lakhs, the difference in the room category might affect the claim settlement. Generally, insurance policies have a cap on room rent. If you've opted for a particular room category in your policy, let's say ₹10,000 (Semi Special Room), and your father chooses a room with higher charges during hospitalization, like the Special Room at ₹12,000 per day, there might be a room rent limit applied by the insurance company. This means they might cover only a certain percentage of the room rent, and you might have to pay the exceeding amount out of pocket.
As per the policy wordings, the Single Private Room, which is considered the most basic and economical, is the Deluxe Room priced at ₹5,000 per day. If your policy mentions that the room rent limit is based on this room category and your father chooses a room higher than this, the excess charges might not be fully covered by the insurance. It's essential to thoroughly review the policy documents and understand the specifics of room rent limits and how they apply in case your father chooses a room category above the one mentioned as the benchmark in the policy.
Before any hospitalization, it's recommended to reach out to the insurance provider or their customer service to clarify any doubts regarding room rent limits and their implications on claim settlement. This way, you can make an informed decision about room selection during hospitalization to avoid any unexpected financial burdens later on. You can reach out to us for further assistance
