Family Health Insurance

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

1. Planned treatment:

When medical treatments are pre-planned, the insured is required to inform the insurer 7 days before admission. Therefore, a 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 a cashless claim settlement, It takes a 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, it settles on a 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, the insured has to inform the insurer about hospitalization within 24 hours of admission.
If the treatment is availed in a network hospital, a cashless claim settlement is availed by the insurer.
On the other hand, treatment availed in a non-network hospital leads to a reimbursement claim. Therefore, in such a case, the insured needs to submit all the original documents within 7 days of discharge.
It takes on an average of 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 a claim plays a crucial role in smooth claim settlement. Immediate intimation is a good practice to follow and generally, there is a turnaround time of 7 days to inform the insurer in case of emergency treatment. In case of a cashless claim settlement, inform the insurer immediately or a week before in case of a pre-planned treatment. Similarly, different insurers assume different claims intimation TAT, you should keep an eye on your insurer’s claims intimation TAT.

2. Timely submission of Documents:

It is crucial to submit all the required documents within the pre-specified time period.
In the case of cashless hospitalization, after intimation, the insurer and the hospital insurance help desk will take care of all the paperwork.
In the case of a Reimbursement claim, be ready with crucial documents such as the claim form, discharge summary, prescriptions, and bills.
Following are the standard documents required to be submitted in case of Health Insurance Reimbursement Claims:

  • Claim Acknowledgement Number (At the time of Intimation)
  • Duly filled claim form with a signed 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.
  • Canceled 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 exclusions:

Before filing a claim, it is important to read the list of exclusions under your health plan carefully. If the cause of hospitalization is restricted under the terms of the policy, it will get rejected immediately.
Generally, the following are the standard exclusions in a health insurance policy:

  • 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 a 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 claims papers and medical bills.
4. Disclose all the material facts to the insurer.
5. For cashless claims settlement, avail medical treatment in a network hospital.
6. Know the payout limit, waiting period, also co-payment applicable to the coverage.
7. Share complete and accurate claim documents with the insurer.
8. Ensure timely intimation and submission of claim documents.
So, experience stress-free recovery of medical expenses by following the above-mentioned tips. A good health insurance plan is one that ensures a timely and smooth claim settlement.