Claim process for your health insurance policy!

By | August 27, 2014

Health Insurance Claim Process

Health insurance provides you protection against expensive treatments. It helps you pay the full cost of medical services when you’re injured or sick. It not only relieves you from financial distress but also gives you confidence to fight those odds in life. With your medical insurance, you can afford the medication cost in your desired hospital and need not compromise on the quality of treatment.

To make the insurance claim experience hassle free, insurance companies are providing world class services to their customers. This includes handling claims processing professionally and compassionately. Although your insurance company sells an insurance plan to you, when you apply for your insurance claim, it is either processed by their in-house team or is outsourced to a “Third Party Administrator (TPA)”. TPA is the organisation or institution authorised by the IRDA and engaged by the insurance company for a fee. It provides policy and claims services to the insured person for an insurable event.

Health Claims can be obtained mainly in two ways:
a) Cashless Claim
b) Reimbursement Claim

Health Claims

Cashless Claim with Network Hospital:

Process for availing Cashless Claim (for planned hospitalization):

There are times when you plan your hospitalization in advance, especially when you know about the occurrence of an event like maternity, surgery etc. In those situations, you might prefer treatment in a hospital of your choice where you can also avail cashless facility through your health insurance plan. Follow the below mentioned process for a hassle free health insurance claim during planned hospitalization:

Step 1: Approach Network Hospital of your choice for Cashless Treatment
Step 2: Contact the Hospital counter that deals in insurance requests, at least 3-4 days prior to the date of hospitalization. Produce your health insurance card to identify yourself as the beneficiary for cashless service.
Step 3: The hospital, after verifying customer details, sends request to insurance company or TPA. Coordinate with network hospital to forward pre-authorization request (by fax) to insurance provider/Third Party Administrator (TPA).
Step 4: Insurance company/TPA reviews your request and authorizes cashless claim services as per the policy benefits and its terms & conditions.
Step 5: TPA sends the response to the hospital. Your claim request may be approved or denied depending on your policy T&C. The time taken for processing and approving cashless claims varies from 1 hour to 1 day (depending on the insurance provider).
Step 6: (i) If your claim is approved, get admitted to hospital without any deposits and avail cashless services as per your plan. On discharge, verify the hospital bills for accuracy. Any amount over pre-authorized limit has to be paid by you at the time of discharge.
(ii) If your claim is rejected due do some reason, proceed with the usual hospitalization process as a cash patient i.e. pay all your bills and later apply for a reimbursement claim with your insurance provider.

Note: Denial of “Cashless Facility” is not denial of treatment. You may continue with the treatment, pay for the services to the hospital, and later submit the claim for processing and reimbursement.

Cashless Claim Process for unplanned/emergency hospitalization:

An individual cannot always plan for his hospitalization in advance. There can be situation when you need life-saving emergency treatment immediately, for instance, in case of accident, unexpected illness etc. For those unexpected moments, keep your family members informed about your insurance details and follow the procedure below for a hassle free claim process:

Step 1: Get admitted to the hospital for emergency treatment
Step 2: Patient or his family members should approach the hospital counter with patient’s health insurance details (Health Insurance Card). This should ideally be done within 24 hours of getting admitted to the hospital. Family members can also contact the insurance provider or TPA directly for sharing health insurance details, in case of lack of assistance from the hospital.
Step 3: Patient’s family members need to co-ordinate with hospital and TPA for arranging the pre-authorization request.
Step 4: TPA will process the request as per policy terms and conditions within defined time period (varies from 1 hour to 1 day).
Step 5: If the request is approved, proceed with cashless services at the hospital else family members need to settle the bills at the time of discharge.
Step 6: If claims were rejected, then proceed with the usual hospitalization process as a cash patient i.e. pay all your bills and later apply for reimbursement claim with your insurance provider.

Whenever you register a loss with claims team (TPA), be ready with the following information:
a) Contact details of insured,
b) Name of the Insured
c) Policy number
d) Date and time of problem
e) Nature of problem
f) Location of problem

If your claim is rejected for cashless hospitalization, you can still apply for reimbursement of your claim by submitting the following documents.

Original Documents to be submitted:
a) “Claim form” duly filled and signed by the beneficiary i.e. the Insured
b) Hospitalization discharge slip/card/summary
c) Hospital bills with their payment receipts
d) Surgical summary (in case the Life Insured has undergone a surgery)
e) All supporting diagnostic reports and prescriptions
f) All Pharmacy receipts and corresponding prescriptions
g) Ambulance invoice, if applicable

Self-attested copies of following documents:
a) Health card or Policy document
b) ID proof of the insured

The documents mentioned are only indications. Based on the circumstances of the claim, the insurer may however, request additional documents.

Tip: It is always important to follow the right process. If your claim is rejected, always verify the reason by calling up the customer care unit of your insurance provider or Third Party Administrator (TPA).

It is also important to know exclusions in your health insurance plan. The common exclusions, for which no payment is made by insurance companies are:

a) Occurrence of illness/hospitalization within 30 days of start of your policy may stop you from all the benefits. Once your policy starts, initial 30 days are considered as a cooling or waiting period. Accident, however, is an exception to this criterion.

b) Treatments received outside India are generally not covered by insurance providers in India. If you are planning for a treatment abroad, it is advisable to check your insurance plan well in advance.

c) Non-allopathic treatment, Cosmetic Surgery, HIV/AIDS, dental treatment (except due to accident), routine eye and ear treatment (cost of routine eye and ear examinations, cost of spectacles, laser surgery for correction of refractory errors, contact lenses, hearing aids, dentures and artificial teeth) etc. are some of the exclusions that most insurance companies do not pay for.

d) Any Pre-existing disease prior to the commencement of your health insurance plan is not covered in the first 2-4 years of the policy depending on your age and the nature of the policy.

Reimbursement Process for Non-Network Hospital:

It may be possible that the hospital that you picked for your treatment or when you were admitted in an emergency is not covered under list of network hospitals of your insurance provider. In that case, you can follow the below mentioned process to avoid chaos at the last moment.

Reimbursement of claims in case of planned hospitalization:

Step 1: Approach the non-network hospital of your choice and inform your insurance provider/TPA at least 3-4 days in advance i.e. before getting hospitalized
Step 2: Get admitted and pay all your bills as a cash customer.
Step 3: Within 7 days of discharge, fill complete details in your claim form and submit it along with other supporting documents (indicative document list mentioned above) to your insurance provider/TPA
Step 4: Your insurance provider/TPA will verify all the documents and settle your claim within 15 days to 1 month of request.

Reimbursement of claims in case of unplanned/emergency hospitalization:

Step 1: Get admitted to the hospital for emergency treatment
Step 2: Patient or his family members should inform the insurance provider/ TPA about insured patient’s hospitalization and share his/her health insurance details (Health Insurance Card). This should ideally be done within 24 hours of getting admitted to the hospital.
Step 3: Pay all your hospital bills at the time of discharge
Step 4: Within 7 days of discharge, fill complete details in your claim form and submit it along with other supporting documents (indicative document list mentioned above) to your insurance provider/TPA
Step 5: Your insurance provider/TPA will verify all the documents and settle your claim within 15 days to 1 month of request.

Tips for faster Claim Settlement:
a) Intimate your insurance provider/TPA immediately (as early as possible) about hospitalization
b) Always repay your insurance premium in time (on/before due date)
c) Submit complete documentation and correct information to your insurance provider

All information including news articles and blogs published on this website are strictly for general information purpose only. BankBazaar does not provide any warranty about the authenticity and accuracy of such information. BankBazaar will not be held responsible for any loss and/or damage that arises or is incurred by use of such information. Rates and offers as may be applicable at the time of applying for a product may vary from that mentioned above. Please visit www.bankbazaar.com for the latest rates/offers.

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