With the world going forward towards development, we can see inflation in everything including growth in healthcare costs. We Indians have opted for suitable health insurance cover because of unexpected growth in healthcare costs. However, many amongst us are not well versed with the nitty-gritty of claiming on the policy, in times required.
Protection from unwelcome and sudden illness, unfortunate hospitalization and related expenses of ones and his/her family is the aim that health insurance holds. Isn’t it enough reason to invest so much time and effort in choosing the right plan and continued to pay the premiums year after year? However, despite its importance, there’s still a lack of awareness about how to claim on a health insurance policy.
How to Claim Health Insurance Successfully
A health insurance policy can be claimed in two ways:
Cashless settlement - As a part of PPN (Preferred Provider Network), every insurance company has a network of hospitals. A policyholder is entitled to a cashless treatment where the insurance company/third party administrator settles the cost of hospitalization and subsequent expenses directly with the hospital without involving the policyholder when you wish to get treated in any of the network hospitals.
Reimbursement of Medical Expenses - In the extreme conditions when the policyholder is unable to get treated at a network hospital, s(he) can opt for the hospitalization and the subsequent treatment in his/her choice of hospital, pay for the same through his/her pocket and then claim for reimbursement. In view of the huge costs involved that you need to bear at the time of discharge from the hospital, this may not appear to be a preferred choice for many.
Health Insurance Cashless Claim Can be Classified Under Two Categories
Claims Against Planned Hospitalization - The medical treatment of diagnosed illnesses is based upon cashless claims against planned hospitalization. The network hospitals that are authorized to offer cashless benefits to the insured on hospitalization and medical facilities are been listed by every insurance company. To avail cashless facility here’s the process to follow:
- With details regarding the network hospital where the insured will be hospitalized, fill up the claim form
- The form is to be sent by email or fax to the insurance company or third party administrator (TPA) for approval of the cashless claim at least 48 to 72 hours before the date of planned hospitalization.
- The insurance company or TPA informs the hospital about the approved claim amount after approval.
- Once the treatment at the hospital completes, the insurance company or TPA directly pays the approved claim amount to the hospital
Claims Against Emergency Hospitalization - Due to an accident or critical illness, such claims are applicable for unforeseen emergencies rising. Here’s the process to be followed by the insured or his/her family members:
- Within 24 hours of hospitalization send the filled up claims form by fax or email and intimate the insurance company or TPA
- The insurance company or TPA takes a decision whether to approve or reject the cashless claims request, after reviewing the form
- The decision is communicated to the insured or his/her family member who had intimated them
Types of Health Insurance Claims
Cashless Claims Form - The policyholders of most of the modern insurance companies are offered the cashless benefit at their respective network hospitals. A policyholder has to follow the claims procedure as mentioned in his/her policy document in order to initiate the process of cashless claims for hospitalization and other medical facilities at a network hospital.
Reimbursement Claims Form - When the insurer does not offer you a cashless benefit or the insured had not been hospitalized at any of its network hospitals, then the only reimbursement of claims are applicable. One has to submit relevant receipts and bills of hospitalization and medical facilities availed by him/her to his/her insurer to initiate the claims reimbursement process, in such cases. Reading thoroughly the policy document for the claims process and the documents that a policyholder needs to submit to initiate the claims reimbursement process with your insurer is a must.
Personal Accident Claims Form - Accidents like accidental death, permanent total disability, and permanent partial disability are covered by personal accident insurance. Hospital and ambulance charges for insured up to a certain limit are also covered by it.
Global Personal Guard - The major work of global personal guard policies is to protect financially the insured against death, permanent total disability and permanent partial disability among other add-on covers. Claims for such expenses have to be made by submitting this form to the concerned insurance company.
Non-Medical Expenses List - Every insurance company holds a specific list of expenses that policyholders cannot claim. baby food, cosmetics, Band-Aid, health drinks, etc are few of these.
KYC Form - A KYC (Know Your Customer) Form with required personal details like name, Proof of Identity (PoI), Proof of Address (PoA), contact number, etc has to be filled by the applicant of a health insurance policy, to enable the insurer to undertake a thorough background check and verify the accuracy of the information provided before offering him/her a health insurance policy.
How to Claim Health Insurance
There are few procedures to enable hassle-free claim process which has been laid down by every insurer. Therefore, it is important to be aware of these processes to avoid any eleventh-hour surprise. Here’s the process to follow for raising successful claims:
For Cashless Settlement
- In case of planned hospitalization, the policyholder has to intimate the insurance company at least 1-2 days in advance. But in case of emergency hospitalization, intimation should be sent to the insurance company within 24 hours.
- Mostly there is a dedicated TPA (Third Party Administrator) helpdesk in the network hospitals that assist insurers with all the necessary documentation and formalities. That is why it’s significant to contact the TPA desk to fill the claim form and submit the necessary documents like health card, doctor’s report, etc.
- After receiving the document by the insurance company/TPA, they are scrutinized to check against the policy coverage and terms.
- Approval is sent to the hospital for a specific amount, if within the scope of coverage. In case the cost of treatment exceeds the approved amount, the hospital can request the reapproval.
- One can pay towards the hospitalization and treatment from his own pocket and then raise the request for reimbursement if the request for cashless treatment is denied.
For Reimbursement of claims
- Intimation to the insurance company is mandatory even if you wish to go for reimbursement, as in cashless settlement.
- The policyholders have to submit the necessary documents to the insurance company/TPA to kick-start the process after the hospitalization post necessary treatment. Here’s the list of documents to be submitted to enable smooth processing:
- Duly completed claim form
- Discharge summary signed by the treating doctor/hospital
- All medical bills along with the related prescriptions
- As per the pre-post hospitalization cover clause in your policy document, you can also submit the expenses/OPD costs related to the hospitalization sought
- Copy of canceled cheque
- Any other necessary documents on the request of the insurance company
- The policy holder’s claim will be accepted/denied basis the policy terms and conditions once scrutiny of the claim request has been completed and the documentation that the policyholder submitted.
- The final amount is disbursed along with the Claim Settlement Letter specifying the break-up of the amount if the claim is accepted.
- Claim Rejection Letter will be shared with the insured stating the reasons for the same in case of the claim is denied on valid grounds
Two Types of Health Insurance Cashless Claim Process
Depending upon the kind of treatment – planned or unplanned, the claims process in case of treatment at a network hospital will differ. Unplanned treatment at a network hospital usually occurs in the event of an emergency.
Planned Hospitalization - To avail the cashless treatment by a policyholder the most essential part is to make the insurance company aware of the nature of illness and get approval for its treatment from the TPA. One needs to fill up the necessary documents for admission, like pre-authorization forms prior to hospitalization. After which these are to be submitted at the insurance desk (every network hospital will have a dedicated insurance desk). On the basis of the terms and conditions listed in the policy, the form will get approved or rejected. If the form is approved, then the TPA will send the sanction letter to the hospital and the treatment can be started thereon.
Emergency Hospitalization - In case of emergency hospitalization, the policyholder can show his or her Health ID card at the network hospital to avail cashless facility. After admission, the preauthorization request can be sent to the TPA. As emergencies are unpredictable it is important to for a policyholder to carry his/her Health ID card at all times. At least the policy number and a photo ID need to be produced at the hospital for pre-authorization in an emergency situation where the card cannot be produced at the network hospital. The health ID card can later be shown at the time of hospitalization. An ‘Emergency certificate’ also has to be submitted with the pre-authorization form to the TPA, stating the emergency nature of admission.
Things to Remember for Claiming Health Insurance
- A minimum of 24-hour hospitalization is mandatory to claim on your health insurance
- The policyholder should refer the policy wording for the terms and conditions related to your plan including the process to follow in case of claims, after receiving the policy documents
- Every insurance company has set certain time frames to follow in case of various processes. Ensure to follow them to avoid any surprises
- The policyholder should be aware of what’s covered and what’s not in his/her health insurance plan. More than what’s covered, it’s important to pay close attention to what’s not
- One should always share a copy of your policy documents, health care and contact details of the insurance company/TPA with his/her family, friends along with the process to follow in case the policyholder is in no position to follow the procedure himself
- The policyholder should keep an eye on the waiting periods for claiming on his/her insurance policy
- Ensure you maintain a proper file with all the prescriptions, medical bills, etc. for easy availability
Why PolicyX Should be Your Ideal Choice?
Being an IRDAI certified broker, PolicyX is well equipped to handle all the queries and concerns regarding claiming on every health insurance policy. Here’s the reason why we can be your ultimate choice:
Claim intimation: PolicyX intimates the claim to the insurance company on the policy holder’s behalf saving a lot of his/her valuable time and efforts.
Documents pick-up: We arrange to pick up all your claim related documents from your home/office as per your convenience.
Documents scrutiny: PolicyX have dedicated and qualified claims team who thoroughly scrutinize every policy holder’s documents for the correctness or any missing information before submitting them to the insurance company/TPA. This saves a lot of time of our customers in back and forth coordination with the insurance company/TPA. The team can also provide a rough estimation of the claim amount that the policyholder can expect to get compensated for.
Follow-ups and status update: We at PolicyX.com understand our customer’s anxiety when it comes to claiming on their health insurance. Therefore, we keep them posted with all the updates related to their claim assuring complete peace of mind. Similarly, we follow up with the insurance company/TPA for the timely disbursement of the claim amount.
Dispute resolution: At last, we will be there for our customers at the most crucial time – when they really need us. In case customers are not satisfied with the outcome of our company’s request, we will raise the same with the insurance company and if required, also help them deal with it through grievance cell. After all, our customers are our priority.