Health Insurance Claims
  • What are Claims
  • Types Of Claims
  • Documents Required
Health Insurance Claims
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Claims In Health Insurance

In health insurance, a claim refers to a formal request submitted by a policyholder to the insurance company, asking for compensation for the medical bills incurred during the treatment at the medical facility. Claims are an important aspect of health insurance as they allow policyholders to receive financial benefits from the purchased insurance policy.

It's important to understand the claim procedures and types of health insurance claims offered by the companies to ensure a smooth claim-filing process and to ensure that the claims are not rejected.

Health Insurance Companies: Policy and Claim Process

Types of Health Insurance Claims

Health insurance offers two types of claims that are listed below:

  • Cashless Claims

    With cashless claims, policyholders can receive medical treatment at a network hospital listed with their insurance provider without paying the bill upfront. Instead, the insurance company settles the bill directly with the hospital, up to the coverage limits of the policy. This can be more convenient for the policyholder, as they don't have to arrange for immediate payment and can focus on their treatment instead.
  • Reimbursement Claims

    In these types of claims, the policyholder can receive the treatment at a non-network hospital as well and settle the bill on his own. Later, the policyholder requests the reimbursement of the medical bills that he has paid for at the hospital from his insurance provider. The policyholder has to submit his original medical bills, and doctor’s prescription to get back the money that he spent on hospitalization. If a policyholder is unable to find a network hospital in case of an emergency he can get admitted to the nearest hospital irrespective of being in the list of network hospitals of his insurance provider.

Process of Claims

The process of filling cashless and reimbursement claims is different. Let us look at both processes one by one.

Cashless Claims Process

Step 1: Claim Intimation

For a planned hospitalization the policyholder has to inform the insurance company 48 hours in advance. For emergency hospitalization, the policyholder has to inform the insurance company within 24 hours.

The policyholder can inform the company via a phone call or email. He can contact the Third-Party Administrator (TPA) available at the network hospital and they will intimate the insurance company. It is advised to get the assistance of TPA for smooth claim intimation.

TPA helps the policyholder in filling out the pre-authorization form and submitting it to the insurance company. The insurance company then approves a specific pre-authorization amount to get the treatment started.

Step 2: Document Verification

After the completion of treatment, the TPA submits the final bill along with all the details of the charges imposed on the treatment to the insurer.

The insurance company reviews the submitted documents and asks for additional documents if required. The insurance company may even send a doctor on deputation to visit the hospital and verify all the treatment procedures.

Step 3: Settlement

Once the assessment is complete, the claim is either approved or rejected. If approved, the insurer settles the claim directly with the hospital. If the claim is rejected, the policyholder can settle the bill out of his own pocket and later apply for a reimbursement claim.

Reimbursement Claims Process

Step 1: Treatment at a Non-Network Hospital

After receiving medical treatment at a hospital or healthcare facility of your choice, settle the medical bills out of your own pocket. Gather all the necessary documents such as medical bills, prescriptions, diagnostic reports, discharge summary etc.

Step 2: Claim Intimation

Inform the insurance company about the treatment and your intent to claim reimbursement. This can often be done online on their official website, via email or a call to the company’s customer services. Once you intimate the company, they will provide you with a ‘Claim Number’ which will be asked by you at the time of filling out the claim form.

Step 3: Document Submission

After the intimation, the policyholder has 30 days to submit the documents to the insurance company to get reimbursement. The documents can be submitted online or offline. But, it is recommended to submit the documents at the nearest branch for a faster reimbursement process.

While submitting the documents online, download the claim form from the official website of the company, fill it in with the necessary details and scan and submit it along with all the asked documents on the official website only in its claims section. However, it's important to note that the insurance company reserves the right to request physical copies of documents if necessary.

While submitting the documents at a branch, ask for a claim form, fill it and submit it with all the documents. The representative at the branch will provide you with a receipt for receiving the documents. This receipt acts as proof of document submission.

The claim form comprises two distinct sections: Form A and Form B. The doctors are responsible for completing Form A by providing treatment details and associated expenses, followed by an official hospital stamp. Policyholders are required to fill out Form B.

Step 4: Processing of Reimbursement

Once the claim is approved, the insurer determines the eligible reimbursement amount based on the policy coverage and terms and transfers the approved amount to the policyholder’s bank account via NEFT within 15 to 30 days.

If the insurance company is not satisfied with the received documents they inform the policyholder about the same and give a specific time to send the additionally asked documents and proofs. Once cleared, the claim either gets rejected or reimbursed. It is to be noted that pre and post-hospitalization expenses can only be availed through reimbursement claims.

Reasons For the Rejection of Claims

Several factors can affect health insurance claims:

  • Coverage Limitations

    Policies often have limits on specific treatments, medications, or medical devices. If the claim exceeds these limits, the insurer might cover only up to the specified amount.
  • Pre-existing Conditions

    Some policies have waiting periods or exclusions for pre-existing conditions. Claims related to these conditions might not be covered during the waiting period.
  • Documentation

    Proper documentation is essential. Incomplete or incorrect information on the claim form can lead to delays or rejections.
  • Medical Necessity

    Insurance companies assess whether the treatment or service is medically necessary. If it's considered elective or not essential, the claim might be denied.
  • Timely Filing

    Claims need to be filed within the stipulated time frame mentioned in the policy. Late submissions might result in claim denials.
  • Claim Fraud

    Intentional misrepresentation of information or fraudulent claims can lead to denials and potential legal consequences.

What To Do When A Claim Is Rejected

The policyholder may ask the insurance company for reconsideration if the claims are denied. Reconsideration of the claims follows a different process for every organization. Here are the common steps taken by the company:

  • If the claims are denied, the insurance firms notify the customer via email 2 to 3 times and wait for the policyholder to apply for reconsideration.
  • The insurance provider may even request any extra documents for verification.
  • The claims will be rejected once again if the policyholder doesn't provide additional information.
  • The company provides a window of 3 to 4 weeks after sending the rejection notification for the client to ask for reconsideration; however, if the customer doesn't object, the window will close and you will never be able to complain about the rejection.

Health Insurer Network Hospitals

Documents Required For Health Insurance Claims

Reimbursement Claims

Here is the list of documents that you require to file for reimbursement for health insurance claims.

  • Original claim form duly completed along with your signature
  • Valid identity proof
  • Doctor’s prescription suggesting treatment in hospita
  • Doctor’s prescription advising diagnostic tests, medicines, and consultation
  • Indoor case papers
  • Ambulance receipt
  • Original pharmacy bills
  • First Information Report(FIR), as required
  • Policy details that include the policy number, name of the insured, address, and disease for which treatment is on
  • Additional documents that may be required to assess the claim, in case there is a fraud

Cashless Claims

Here is the list of documents that you require to file for Cashless claims in health insurance.

  • Claim pre-authorization form
  • Health card or policy details
  • Valid ID proof and a photograph
  • Documents such as PAN Card, Voter ID, Driving License, and Aadhar card

The claim form and the documents should be sent to the Insurer or the Third-party Administrator.The documents required for cashless claims in a network hospital are different from the ones required for registering a reimbursement claim.

Conclusion:

Understanding medical insurance procedures is crucial for availing of financial assistance during medical emergencies. Following the correct steps and keeping the documents in order policyholders can ensure smooth and timely claim approvals. It not only provides financial security but offers tax benefits making it a wise investment for the individual and family.

Health Insurance Claims: FAQs

1. How to claim health insurance online?

Health insurance can be made online. Visit the official website of the company and intimate the company about the claim. The company will arrange a call back from the executive and they will guide you through the process.

2. What happens in case of claim rejection?

In case of claim rejection, the company will inform the policyholder and ask them for more documents and details if required.

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Bindiya Sinha

Written By: Bindiya Sinha

Bindiya is a seasoned content writer specializing in keeping readers acquainted with the insurance industry, term insurance developments, and life insurance sector shifts. With an experience of 3 years in insurance, Bindiya ensures that her readers stay well informed with the insurance developments and factually correct information.