Health Insurance 174 views February 18, 2019

Health Insurance Claims

What is the point in buying health insurance if you are unaware of how to make a health insurance claim? The intent behind buying a health insurance policy is to ensure that costs of hospitalization and consequent medical treatment are covered under the same.

Different Types of Health Insurance Claims

Making a health insurance claim is not so complicated as it may seem. Prior knowledge of the process coupled with the submission of necessary documents ensures that your health insurance company takes care of the expenses or reimburses the amount spent on treatment as predetermined in the policy document.

You may make a claim on your health insurance policy through:-

Cashless Settlement

Every health insurance companies are tied up with a network of hospitals that form a part of the company’s Preferred Provider Network. In the event of the policyholder seeking treatment at any of the hospitals included in the network, he or she will be entitled to the benefits of cashless treatment. The concerned insurance companies or Third Party Administrator (TPA) settles the bill that the hospital raises for hospitalization and subsequent expenses on treatment.

In most health insurance policies, opting for cashless settlement is the norm. This is because most policyholders choose this option as this allows them to seek treatment without having to go through the hassles of filling in forms and claiming reimbursement. The insurance company hands over two different documents to the policyholder. While one document contains a list of all the hospitals within the company’s network, the second is an identity card. The identity card includes contact details of the TPA appointed by the insurance company. This means that the policyholders must prefer to get treated at one of the hospitals empanelled in the insurer’s list.

The cashless claim settlement process has a lot to do whether the policyholder is claiming the expenses on planned treatment or has had to undergo a sudden and emergency hospitalization.

To avail cashless treatment in case of:

Planned Hassle-free hospitalization

Before planning to undergo treatment at a hospital empanelled in the insurance company’s network, it is important to inform the insurer about the nature of illness for which treatment is being sought. In addition, the policyholder must fill necessary documents for admission like pre-authorization forms and seek approval for treatment from the insurance company or the relevant TPA. The policyholder has to submit the forms at the insurance desk of the network hospital. Depending on the illness for which you are seeking treatment and the terms and conditions of the policyholder, the insurance company will accept or reject the claim. If the admission form is approved, the TPA will email the sanction letter to the hospital, thus, signalling commencement of the necessary treatment.

Unplanned/Emergency hospitalization

In the event of sudden hospitalization, the policyholder or the concerned family member can show the Health ID card issued by the insurance company at the network hospital. Showing this card helps avail cashless facility. The pre-authorization request along with the necessary documents can be sent to the TPA post-admission. If for some reason, the policyholder is unable to produce the Health ID card at the network hospital, the accompanying family members can submit the policy number and the photo ID of the policyholder at the hospital to ensure authorization for treatment by the health insurance company. The Health ID card can be submitted later during the course of the policyholder’s hospitalization and subsequent treatment.

Reimbursement of Medical Expenses

There are times when a policyholder is unable to seek treatment empanelled in the insurer’s list and, hence, seeks treatment at a different hospital. The policyholder is then required to pay the hospital expenses and then seek a claim for reimbursement. Though most health insurance policies allow greater scope for cashless settlement, a few health insurance policies stress on settlement through the reimbursement process only. However, since the costs of treatment are high, the reimbursement claim settlement process is not preferred by many.

Why Is Cashless Settlement Preferred?

“Which is better?” is a question that interested customers continue to inquire about. Though lack of knowledge about the insurance and its benefits has resulted in many people making a wrong choice of policy in the past, it is obvious that the cashless settlement is definitely a much easier and hassle-free process.

The biggest benefit of opting for cashless settlement is that it saves you from the imminent financial crisis that stems from paying hospital bills from one’s own pocket. Hassle-free and easy, most customers opt for cashless settlement while buying a health insurance policy.

However, in the event of an emergency, a policyholder may have to be hospitalized in a non-network hospital, thus, prompting him or her to avail reimbursement claim settlement.

How To Claim Your Health Insurance Policy?

As opposed to the common opinion about the health insurance claim being complicated, it is easy provided one is aware of certain processes governing hassle-free claim settlement.

Steps For Cashless Claim Settlement

  1. Inform in writing to the insurance company at least one or two days before getting admitted to the hospital in case of planned treatment. In the event of emergency hospitalization, the insurance company must be intimated within 24 hours of admission.
  2. Inform your concerned TPA about the hospitalization. In the case of planned hospitalization, approach the helpdesk of the hospital with necessary documents. Since most of the network hospitals will have access to a dedicated TPA, it is imperative to get in touch with the TPA desk and submit the claim form filled in with necessary details along with associated documents including the Health ID card, doctor’s report, etc.
  3. The insurance company or the concerned TPA examines the documents received and assesses them against the coverage bought along with the terms and conditions are given in the policy.
  4. If the estimated expenses on the treatment are within the scope of the health insurance coverage, the TPA sends a letter of approval to the hospital. However, if the treatment costs exceed the approved amount, the hospital may send another request to the TPA for re-approval.
  5. If due to any reason the insurance company denies cashless settlement for the treatment sought, the policyholder may pay for the treatment and then raise a request for reimbursement of the amount spent on hospitalization and treatment.

Steps For Settlement Through Reimbursement

  1. Intimation to the insurance company about the treatment intended is important for seeking claims through reimbursement.
  2. After the treatment has been completed, the policyholder is required to submit certain necessary documents to the insurance company/TPA to initiate the claim settlement process.
  3. Post evaluation of the claim settlement request form and associated documents, the insurance company may accept or reject the claim.
  4. If the insurance company accepts the claim, then it will credit the amount to the account of the policyholder or the nominee, as mentioned in the policy proposal form, along with the Claim Settlement Letter giving particulars of the break-up of the claim amount.
  5. In the event of rejection of the claim amount, the insurance company will share the Claim Rejection Letter with the policyholders while mentioning the reasons for claim rejection.

Documents Necessary For Health Insurance Claim

  1. Claim form duly filled in with all details and signed by the policyholder
  2. Prescription signed by the doctor advising admission for treatment
  3. Discharge form issued by the hospital
  4. Original bill issued by the hospital along with the payment receipt
  5. Medical reports issued by the hospital
  6. Bills from chemists showing the amount expended on medicines along with supporting prescriptions
  7. Invoice for implants (if used during the surgery)
  8. FIR lodged in case of road accidents leading to the treatment
  9. Cancelled cheque of the bank in which the policyholder would like the amount to be credited post payment of
  10. the claim by the insurance company through NEFT.

Expenses Not Covered Under Any Health Insurance Claim

Irrespective of the choice of insurance company one makes, the following expenses are not covered under any health insurance claim. These include:-

  1. Administrative Charges
  2. Service Charges
  3. Laundry Expenses
  4. Expenses on the provision of an additional bed
  5. Expenses on tampons and diapers
  6. Expenditure on syringes and thermometers
  7. Telephone charges.

Filing Health Insurance Claims Online

As insurance companies focus on advanced technological tools to enhance the working of their sites, it has become possible for policyholders to file their health insurance claims online too. Depending on the policy terms and conditions coupled with the facility advanced by the insurance company/TPA, policyholders can file their claims online too.

Can One Claim From Two Health Insurance Policies?

Depending on the number of health insurance policies one has bought, health insurance claims can be made. If the billing amount (or the amount claimed) on one policy is more than the sum assured under the policy, then the policyholder may opt to claim the remaining amount from the second policy bought.