Follow these steps to avoid last-minute surprises while claiming your health insurance -- via cashless or reimbursement method, says P V Subramanyam
When you pay your health insurance premiums on time, it is only natural to expect the policy to cover your medical expenses on filing a claim. However, understanding health insurance claims can get complicated at times leading to rejection which can come as an ugly surprise at the time of need.
So, here's a simple guide to help you with the most important know-how of claiming health insurance.
Types of Health Insurance Claims:
1. Reimbursement Claim: In a reimbursement claim, your insurance company compensates your out-of-pocket expenses during treatment or surgery in a non-network hospital. The company reimburses the complete or partial amount based on the policy guidelines and original medical documents you submit.
2. Cashless Claim: A cashless medical claim allows you to go undergo a medical treatment or surgery without having to pay the bill from your pocket if the hospital is within the network of your insurance company. The insurance company then settles the bill amount or a part of it with the hospital depending on the terms and conditions of your policy.
Now that you know what cashless and reimbursement claims are, let's find out how to claim health insurance.
Steps to Claim Reimbursement:
1. Intimate the Insurance Company: The insured must send intimation to the insurance company via e-mail, call or web site before filing a reimbursement.
When the hospitalisation is planned, the insured must intimate the company 3 to 4 days prior to the admission. In case of emergency, the insurance company must be informed within 24 hours of hospitalisation.
2. Gather Documents: Arrange the original medical documents in the right order as per the policy and send them out to the insurance company. The documents include:
a. Copy of Government ID Proof with Insurance card
b. Original Hospital Discharge Summary
c. Original Itemised Bills
d. Hospital Bill and Breakup
e. Original Investigation Reports
f. Original Pharmacy Bills
g. Original Prescriptions
h. Copy of FIR/Medico-Legal Certificate (only in case of accidental injury)
i. Original Cancelled Cheque
3. Fill and Submit the Claim Form: Fill the claim form by hand or online and attach all the original documents required before submitting the form.
4. Track Claim: Visit the insurance company's Web site or call their customer care number or if your insurer is associated with TPA call their TPA (Third Party Administrator) to track the progress of your claim process.
5. Resolve Query, If Raised: If the insurer finds any discrepancies in your form or documents, they raise a query which must be resolved by the insured within 7 to 10 business days as specified by the TPA. You may need to submit more documents to justify the claim.
6. Get Your Claim Settled: When all your documents are verified and you resolve the query raised, if any, on time, the insurance company approves the claim and reimburses the medical expenses as per the policy guidelines.
Cashless Claim in four Simple Steps
1. Pre-authorisation: Hospital initiates pre-authorisation at the time of admission of a policyholder to verify their eligibility to claim for the estimated medical expenses. The process requires the insured to present a government-approved ID card and the health insurance policy card at the time of admission.
2. Enhancement During Admission: If the hospital establishes that the estimated medical expense sent out to insurance company for pre-authorisation may increase, they send out a new estimated figure known as enhancement during admission.
3. Queries in Cashless Admission: If the insurance company finds discrepancies during pre-authorisation, it raises a query which must be resolved within 24 hours. Hence, to establish trust and verify the admissibility of the claim, the hospital is required to submit additional material facts.
4. Cashless Discharge: The insurance company settles the payment directly with the hospital based on the policy terms if these four conditions are met:
- Insurance company has all the data points
- The hospital justifies the need for hospitalisation of the patient
- All the original documents are submitted to the insurance company
- The financial parameters are as per the policy guidelines
These steps will help you steer clear of the most common mistakes people make while filing a claim.
So, follow them and avoid any last-minute surprises.
- Money-related questions? Ask rediffGURUS HERE.
P V Subramanyam is a chartered accountant with more than four decades of experience in the field of personal finance and blogs at subramoney.com.
Disclaimer: This article is meant for information purposes only. This article and information do not constitute a distribution, an endorsement, an investment advice, an offer to buy or sell or the solicitation of an offer to buy or sell any securities/schemes or any other financial products/investment products mentioned in this article to influence the opinion or behaviour of the investors/recipients.
Any use of the information/any investment and investment related decisions of the investors/recipients are at their sole discretion and risk. Any advice herein is made on a general basis and does not take into account the specific investment objectives of the specific person or group of persons. Opinions expressed herein are subject to change without notice.
