The reimbursement claim process is a pain point most health insurance customers have experienced before. With the high cost of healthcare in the UAE, residents have to pay a significant amount from their own pocket. Waiting for the insurance company to pay you back can be a stressful process to say the least.
A health insurance reimbursement claim refers to a bill or expense that you paid, and are covered for under your policy, that the insurer must pay you back for. In the UAE, it takes an average of 51 days for health insurance companies to reimburse policyholders. In addition, there is always a possibility that the insurer rejects your claim or does not reimburse you for the full amount.
What exactly happens when you make a claim? What factors does the insurance provider look at when accepting or rejecting a claim?
One important aspect that you must keep in mind when making a reimbursement claim is that your health insurance company may not always reimburse the entire amount. This is especially true when you go outside of the medical network covered by your health insurance policy. Here are a few factors that need to be considered when making a claim:
In the UAE, many health insurance plans have a waiting period during which no claims will be covered. Typically, specific benefits or treatments will have their own waiting periods, although this varies from one policy to another. It is very common for pre-existing conditions to have a 6 month waiting period. Maternity and dental benefits also typically have waiting periods that can range from 30 to 90 days. When making a claim, medical insurance policyholders must check the waiting period for the illness for which they are getting treatment. If the treatment is received during the waiting period, the claim will be rejected.
Hospitalisation room charges
While a typical insurance plan covers room charges at the time of hospitalisation, there may be a cap on the nightly rate the health insurance company will cover. If the claim amount is higher than this limit, the insurance company will not reimburse you for the full amount.
Co-pay, or co-insurance, is different from deductible in that in the case of the latter, the insurance company defines a set amount that the insured must pay during every visit to the healthcare provider, whereas with a co-pay, the customer has to pay a fixed percentage of the overall cost of treatment. When reimbursing the claim, the insurance company will deduct the policyholder’s percentage from the overall admissible claim. Most individual health insurance plans will have a co-pay for any treatments received outside of the medical network. This is typically 20% of the cost, and is in addition to any deductibles you have to pay.
Usual, customer and reasonable (UCR) charges
When receiving treatment outside the network, most health insurance companies in the UAE reimburse you based on the UCR rate. For example, if the treatment cost you paid is AED 1,000, but the cost of the same treatment in the insurer’s medical network is AED 600, you will be reimbursed a percentage of the AED 600 even though the actual cost of the treatment was more.
In certain scenarios, policyholders might find themselves in situations where the health insurance company rejects their claims. The below checklist can come in handy when probing the claim rejection:
- Whether the person receiving treatment was covered under the policy?
- Whether the treatment taken was covered within the policy?
- Whether the healthcare facility was within the network or out of network?
- Whether there are any deductibles or co-payments?
- Whether the policy was valid at the time treatment was done?
Here at Bayzat, we continually stress the importance of staying within the network to avoid reimbursement claims. Our platform, Bayzat Benefits, makes it easy for customers to take advantage of direct billing by providing an intuitive map of hospitals, clinics and medical facilities in the UAE that is customized to their respective insurance policies.
In the scenario that you go outside the network or are receiving medical treatment on a reimbursement basis, it is always a great idea to have a quality, customer-oriented insurance broker on your side. Here at Bayzat, not only will our team & partners fight on your behalf to make sure the insurance company covers your claim, but we also actively follow up with insurers to expedite the process as well.