Get Aware of Health Insurance Claim Process

You might have bought the best health plan after thorough research, but what if you get hospitalised and you don’t know the appropriate process to file a claim? What if you don’t meet the terms of the plan and your claims get rejected? All that time was taken and money invested to buy a foolproof health plan will come down to zilch if your claims are not filed in order, as per the requirements of the insurance company.

Before we understand the claim process, let’s have a look at the types of claims:

Cashless:

This can be either a planned hospitalisation or in an emergency. However, the claim process remains the same; the only difference is in the time frame to file for the claims. In case of a planned hospitalisation, you have to adhere to the following claim process 7 days before getting admitted and in case of an emergency, you have to follow it within 24 hours of getting admitted:

  1. Inform the insurer of hospitalisation.
  2. Get admitted to a network hospital, show the third party administrator (TPA) present in the hospital your health insurance id card with which they will access your insurance details.
  3. Based on it, the hospital authorities along with the TPA will fill up a pre-authorisation form with the details, medical scans, other required documents, etc. and send it to the insurer for approvals.
  4.  Once the insurer is satisfied with the documentation and your eligibility for the cashless claim, it will authorise the hospital to proceed with the cashless media claim facility.
  5.  At the time of discharge, the hospital will send the final bills, complete medical records and other supported documents to the insurer for final settlement. After considering deductibles, co-payments and other exclusions from the insured’s policy, the insurer will settle the remaining claim and any balance amount will have to be paid by the insured himself.

Reimbursement:

This is where you pay the bills for medical treatment on your own and later file the claims with the insurer for reimbursement. In the case of reimbursements, there can be a claim from a single insurer or there can be multiple claims from multiple insurance providers.

Reimbursement Claim Process from Single Insurer:

  1. The first step is to inform the insurer immediately at the time of hospitalisation.
  2. After being discharged from the hospital, you have to fill up the claim form. It is available on every insurance company’s website.
  3. To ensure your health insurance policy claims are approved, make sure that you attach all relevant and required documents in Original with the claim form. These include medical reports, hospital bills, final discharge summary, diagnostic tests, etc.
  4. Be ready for any other documents as required by the insurer. Keep following up with the TPA to keep track on whether they have received the documents and whether some more information needs to be furnished with them.
  5. If everything is in order, the claim should be approved in 30-40 days or as per the specified turn around time of the insurer.

Reimbursement Claim Process for Multiple Insurers:

  1. Inform all the insurers at the time of hospitalisation.
  2. After getting discharged, select the company with which you want to file the claim first and fill their form.
  3. Attach all documents and required bills with the form in Original and submit them.
  4. Collect attested copies of all documents from the hospital to be submitted to other insurers as photocopies are not acceptable as per terms of the claim.
  5. Once the insurance company settles your claims as per the terms of your health policy, they will issue a letter that they have the original documents and claim is settled.
  6. To get further health insurance benefits, attach the above-mentioned letter with the form and set of documents for the second insurer and submit it with them. Also, mention in a cover letter that you have received X amount from insurer A against your claim.
  7. If you have any more insurers, repeat the same process as explained above.

Do remember that the insurance companies won’t mind clearing your claims provided they are in order. Therefore, to enjoy the health insurance benefits, read the terms of your policy document carefully, understand the limits mentioned, be aware of the documentation required and file for claims accordingly.

If you have done everything as per the requirements, your claims will undoubtedly be approved.

Harjot Singh Narula

Harjot Narula is founder and CEO of ComparePolicy.com, an IRDAI approved insurance web aggregator focussed on selling online insurance for companies. Harjot has more than a decade of experience in software development and has also spent 5 years in US working for the mortgage and risk management industry.

Leave a Reply

Your email address will not be published. Required fields are marked *