A health insurance claim is a request to your health insurance company to avail of the benefits covered under your health insurance plan. Being able to afford health care services whenever required is the true utility of a health insurance plan. Timely and hassle-free claim settlement of all the medical expenses is what everyone looks forward to. Claim settlement can be a tedious process, but we have simplified the same in a step-by-step process below. There are two ways in which you can file your health insurance claim.
In case the hospitalization is planned, you may opt for a Cashless Claim Settlement. The Cashless claim settlement would be done by getting admitted in any of the empanelled hospitals that falls under the health insurer’s network. Here you simply have to produce your health card issued by the health insurer and avail cashless treatment. The insurance company directly settles the bill with the hospital. A cashless claim gives you a sense of relief even when you are travelling and takes care of the costs in case of any medical emergencies.
In a Reimbursement claim, you make the hospitalization and medical bill payments directly to the hospital and then make a claim to get the reimbursement done by your health insurer after submitting relevant documents. There are certain health insurance plans that do not offer cashless claim facility and hence you have to get the reimbursement of the expenses done. You can get the treatment done in a non-network hospital in case you fail to get the benefit of cashless health claim.
Intimate: Register a cashless claim by informing your health insurance company at least 1-2 days prior in case of planned hospitalization. In case of an emergency hospitalization, you should inform the health insurance company within 24 hours
Submission of documents: Get in touch by flashing your health cards at the Third-party Administrator (TPA) helpdesk and complete the formalities required
Form filling: Fill-up the claim form and submit a doctor’s report and other relevant documents
Record keeping: The Health Insurance Company/ TPA would carefully investigate for the scope of coverage under your health insurance policy. Post scrutinizing, the cashless claim would be approved. In case of rejection of the same, the health insurance company may retain your original documents pertaining to the hospitalization. Thus it is suggested to ask for a copy of the same for your reference.
Pre-Post hospitalization: Always check the health insurance policy document for the pre and post hospitalization cover. All you need to do is retain the medical reports/ prescriptions/ bills, etc. in order to make a reimbursement health claim
Intimation: Inform the health insurance company within 30 days from the date of discharge from the hospital.
Document submission: Post hospitalization, it is necessary that you submit the below mentioned documents in original to the health insurance company to get the reimbursement done at the earliest. It is important that the registration number of the hospital, name of the patient and the date on the hospital bill should be clear and accurate.
Claim form duly filled and signed
Medical bills, test reports and diagnosis with prescriptions
OPD costs related
Discharge card: Once you are discharged from the hospital, you will be given a discharge summary/ card that would mention stating you are fit to be discharged. Ensure you submit this important document in original to the health insurer along with the above mentioned documents for a smooth reimbursement of expenses.
Retention of copies: The health insurance company would carefully investigate for the scope of coverage under your health insurance policy and basis would either approve or reject your reimbursement claim. In case of claim approval, a claim settlement letter mentioning the break-up of the reimbursed amount would be sent once the amount is disbursed. A claim rejection letter mentioning the valid reasons would be shared in case of rejection of the reimbursement claim. It is therefore important that you retain all the copies of the submitted documents for your future reference.
Even if the hospitalization is less than 24 hours, your health insurance is applicable. A daycare procedure that leads to a surgical treatment under a local or a general anaesthesia would require less than 24 hours of hospitalization. But, Out-patient department (OPD) doesn’t count in this category. Few examples of a daycare treatment are dialysis, prostate, eye surgery, piles/fistula, angiography, etc.
Knowing the protocol of registering a claim is very important. There might be emergency situations wherein you get admitted to a non-network hospital. You will be required to pay the hospital and other medical bills and then claim reimbursement from your health insurance company. It is important that you know the documents required to make a reimbursement health insurance claim.
A cashless health insurance can be denied in case the hospitalization takes place in a non-network hospital.
· First Consultation paper
· Duly filled and signed claim form
· Supporting documents for the diagnosis of the critical illness
· Surgical and past medical history from the attending physician’s report
In case you wish to avail a cashless treatment, it is important that you ensure that the said ailment is covered as per your policy terms and conditions. If the said ailment is allowed, take an approval from the TPA to avail the medical treatment. A pre-authorization form needs to be filled in prior to hospitalization. You then need to submit the same at the insurance desk in the hospital. This form will either get approved or rejected based on the policy terms and conditions. The TPA will then send the approval letter to the hospital, post which the treatment can commence.
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