Health Insurance 2188 views March 4, 2019

How to Make Health Insurance Claim

Steps to Make Successful Health Insurance Claim

Policyholders buying health insurance are mostly unaware of how to make claim, if and when the need arises. Most health insurance companies selling a health insurance policy and plans offer two kinds of benefits including cashless mediclaim policy facilities or the reimbursement mode.

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Cashless Mediclaim Policy

This facility ensures that you do not have to go through the hassles of withdrawing your hard-earned money from the bank to pay for your hospitalization or medical bills. The policyholders opting for this are ensured seamless treatment as the medical bills are settled between the insurance company and the hospital subject to the condition that the billing amount is not more than the sum assured and within the individual treatment limits. However, these benefits are available only if the treatment has been carried out in any of the network hospitals tied with the concerned insurer.

The procedure that the policyholder would be required to follow to avail cashless benefit claim depends on whether the admission at the hospital is planned or unplanned.

  1. Procedure for seeking cashless settlement if the admission at the hospital is planned
  2. Inform the insurance company about the intent to seek treatment in a network hospital.
  3. Seek prior authorization from the insurance company regarding the treatment. Generally, it does not take more than a couple of days to seek approval before the treatment, though the same may vary from one insurance company to the other.

Submitting Necessary Documents at the Network Hospital Including:

  1. Pre-authorization letter from the insurer
  2. ID Card issued by the insurer
  3. Health Insurance Policy Documents
  4. Aadhar Card
  5. PAN Card or Form 60 for those without the PAN Card.
  6. Post-treatment, it is important that the policyholder leaves behind the original bills with the hospital. The hospital then submits these bills to the insurance company, subsequent to which the bills are settled and the necessary payment is made.

Procedure for Seeking a Cashless Settlement in Case of Sudden or Emergency Treatment

In case the policyholder needs sudden medical treatment or in the face of an emergency, the policyholder may simply inform the insurer by calling at the customer care center or detailing about the same through the insurance companies chatbots to know if the hospital nearest to your place is within its network. The customer can seek the benefits of cashless hospitalization by submitting the insurance card issued by the insurer along with a copy of the policy. In most cases, the insurance company authorizes payment of the medical bills raised by the hospital within a few hours of the last document received.

Reimbursement Health Insurance

The policyholder may be fraught with sudden emergency situations, thus, necessitating admission in a hospital external to the insurer’s network. Since the hospital is not listed with the panel of the insurance company, the policyholder would be required to pay off the bills corresponding to the medical treatment sought and later submits the bills along with the claim made for reimbursement.

The procedure of getting medical bills reimbursed from the insurance company remains the same irrespective of whether the policyholder is seeking emergency or planned treatment from any hospital.

Procedure for Getting Medical Bills Reimbursed

At the time of filing the claim, the policyholder must submit necessary documents in addition to the original medical bills to the insurance company. These documents include:-

  1. Claim form with details filled
  2. Bank details of the policyholder
  3. Aadhar Card or PAN Card of the policyholder
  4. Hospital Discharge Summary
  5. Diagnosis reports and supporting bills;
  6. Original bills of payment made to the hospital
  7. Bills corresponding to medicines bought from the pharmacy.
  8. In case of hospitalization resulting from accident, the insurance company would require a copy of the FIR filed with the nearest police station.

The insurance company evaluates the documents received from the policyholder and makes payment accordingly provided that the amount corresponding to the bill does not exceed the predetermined amount of sum assured. However, the insurance claim may get rejected on certain unforeseen grounds for which the insurance company will be required to submit necessary reasons and supporting details.

It must be remembered that people buy health insurance to offset the rising expenses on hospitalization and medical treatment. However, it is always advisable to know the individual limit on various procedures allowed by each insurer before opting for the one that would suit you best. Also, complete knowledge and timely premium payments ensure that the claims are made timely and in full, thus, ensuring optimum benefits from the health insurance plans bought.

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