Page 87 - MEDICAL AND HEALTH INSURANCE

MEDICAL AND HEALTH INSURANCE

necessary and within the ambit of the policy proviso and the charges are reasonable

and customary.

With the full documentation, including medical report, received the claim assessor
will do the eligibility check in terms of the condition of the diagnosis and treatment as

follows:

 Is the condition pre-existing?
 Is there a co-payment or deductible to be applied?

 Is the treatment or surgical procedure consistent with the admitting diagnosis?

 Is there any non-related treatment done out of the convenience of the

physician or upon request by the claimant?

 Is the final diagnosis different from the admitting diagnosis?
 Is the treatment medically necessary?

 b) Is the condition under specified illness? •

 Is the condition congenital or under policy exclusion?
 Is it within the limits of the policy or has exhausted the limit?

 Is there a waiting period to be applied?

If there are doubts or grey areas, the claim assessor will use the relationship with the

provider to seek a clarification of the condition. Otherwise, the assessor will write to

the provider or medical specialist for clarification or investigation, if necessary.

PAYMENT

Having established the eligibility of the treatment, the next step is to determine the

quantum of the benefit payable. Medical and health insurance policy insurance
contracts are contracts of indemnity, which in principle "puts back the Insured in the

same financial position as he was before the loss". In this context, it does not mean

that all claims must be paid in full or result in settlement, as the eligibility must be

within the proviso of the policy terms and conditions.

In determining the payment quantum, the process is as follows:

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