Making A Claim Under Health Insurance, Keep These Things In Mind

Health Insurance is a lifesaver protection plan. It keeps you solvent at the time of medical issues. As medical cost is shooting up, it becomes crucial to consider smooth claim settlement process as a key factor while buying your health insurance policy. Always, check the claim settlement ratio of insurers in order to buy the best health insurance plan.

A health insurance claim is settled either on a cashless basis or reimbursement basis depending upon the terms of policy or treatment availed in network or non-network hospitals.

When a health issue crops up, making a claim depends upon the type of treatment to be availed by the insurer:

1. Planned treatment:

When medical treatments are pre-planned, insured is required to inform the insurer 7 days before admission. Cashless authorization form needs to be submitted. The cashless authorization form is available at the TPA help-desk in the hospital.

Read About: Reimbursement Vs Cashless Claim Settlement

In case of cashless claim settlement, It takes the minimum of 4 hours to approve cashless treatment after receipt of complete information from the network hospital.

When a treatment is not availed in a network hospital, the claim is settled on the reimbursement basis. In case of reimbursement basis, the insured should submit original claim documents within 7 days of discharge.

2. Emergency Treatment:

In case of emergency treatment, insured has to inform the insurer about hospitalization within 24 hours of admission.

If the treatment is availed in a network hospital, cashless claim settlement is availed by the insurer.
On the other hand, treatment availed in a non-network hospital leads to a reimbursement claim. In such case, insured needs to submit all the original documents within 7 days of discharge.

It takes on an average 20 working days from the date of receipt of complete information for claim settlement.

Making a claim comes with a few important tasks:

1. Keep a note of Claim Intimation TAT:

Timely intimation of claim plays a crucial role in smooth claim settlement. Immediate claim intimation is a good practice to follow and generally, there is a turn around time of 7 days to inform the insurer in case of emergency treatment. In case of cashless claim settlement, inform the insurer immediately or a week before in case a pre-planned treatment. Different insurers assume different claim intimation TAT, you should keep an eye on your insurer’s claim intimation TAT.

2.Timely submission of Documents:

It is crucial to submit all the required documents within the pre-specified time period.

In case of cashless hospitalization, after intimation, insurer and the hospital insurance help desk will take care of all the paperwork.

In case of Reimbursement claim, be ready with the crucial documents such as claim form, discharge summary, prescriptions and bills.

Following are the standard documents required to be submitted in case of Health Insurance Reimbursement Claim:

  • Claim Acknowledgement Number (At the time of Intimation)
  • Duly filled claim form with a sign and lodged Amount.
  • Prescription details by treating doctor/surgeon.
  • Discharge Card/Discharge summary in the original.
  • All original bills & receipts.
  • Investigation Reports.
  • X-ray, ECG/Films if any.
  • Cancelled Cheque of Employee with his pre-printed name on it along with filled EFT Form.
  • Original implant certificate.

Read About: Different types of Health Insurance plans to cover medical costs

3.Mind the list of exclusion:

Before filing a claim, it is important to read the list of exclusion under your health plan carefully. If the cause of hospitalization is a restriction under the terms of policy, your claim will get rejected immediately.

Generally, the following are the standard exclusions in a health insurance plan:

  • Change of gender.
  • Weight management services and treatment related to weight reduction.
  • Cosmetic surgery.
  • Experimental, unproven or non-standard treatment.
  • AIDs/HIV
  • Intentional self-injury and use of intoxicating drugs/alcohol.
  • Dental treatment (root canal, filling etc)
  • Spectacles, contact lenses, hearing aids and all other external appliances and/or devices whether for diagnosis or treatment.

Tips to ensure smooth claim settlement:

1. Always collect and maintain a proper record of your medical report.

2. Collect Discharge summary, original bills, prescriptions, pharmacy receipt, a copy of investigation reports etc from the hospital.

3. Keep at least one copy of all the claim papers and medical bills.

4. Disclose all the material facts to the insurer.

5. For cashless claim settlement, avail medical treatment in a network hospital.

6.Know the payout limit, waiting period and co-payment applicable on the coverage.

7. Share complete and accurate claim documents with the insurer.

8. Ensure timely intimation and submission of claim documents.

Experience stress-free recovery of medical expenses by following the above-mentioned tips. A good health insurance plan is one which ensures timely and smooth claim settlement.

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