Claims In Health Insurance

Types of Health Insurance Claims

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

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:

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.

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.