Health Insurance Claims – Everything You Need To Know (English)

Imagine you have been living in a rented house and saving each month to buy a house of your own. Unfortunately, you get ill and a substantial amount is spent from the hard-earned savings on your medical expenses. Your long-awaited dream of buying a house is shattered and you are in distress.
The expenses could have been curtailed if you had opted for a health insurance policy.

Health Insurance plays a very important role in the Indian health scenario. Health insurance policies help in reducing the costs incurred during unpredictable medical emergencies.  With so much inflation, recessions and so many new diseases spreading all over, it is vital for each family to opt for a particular health insurance policy to avoid indebtedness.

However, not only health insurance, one should be aware of the health insurance claim, too. This would reduce anxieties and worries in the long run. Health insurance can be claimed cashless as well as on a reimbursement basis. The claim process involves a bit of paperwork, which requires thorough knowledge of the claim process. This article will help you to understand the process of insurance claim better.

Before we explain the process of an insurance claim, let’s throw some light on the Cashless and Reimbursement method.

 

1. Cashless Facility

The insurance company that has your policy must have some approved network hospitals that ensure that if the insured person is admitted to one of them, he/she does not have to pay cash for the expenses incurred. Except for a few non-medical bills, everything else can be settled without cash payment. This is the most hassle-free way to pay for the treatment with health insurance.

 

2. Reimbursement Process

If for any reason, the insured person is unable to admit himself to the approved network hospital of the Insurance Company, a number of documents like a medical bill, receipts, prescriptions, medical reports are to be submitted at the Insurance company. Thorough scrutiny is done by the Insurance company and then the claim amount is reimbursed to the bank account of the insured person.

 

Cashless Facility

The following points are for a better understanding of Cashless Facility in Health Insurance Claim.

Different hospitals may have different norms regarding health insurance policies. The Individual policy may be different from the Corporate Group policy. Therefore, it is necessary to know the system and how it works in detail.

Once the patient is admitted to the hospital, the following documents to be submitted to the Claim Department are as follows –

1. Latest policy copy
2. KYC documents
3. Prescription containing the doctor’s advice to admit
   

The hospitals enlisted under your insurance company change from time to time. Therefore,  before admitting the patient, one needs to check if the hospital still has a tie-up with the insurance company. Usually, the Hospital desk completes all the formalities of Cashless Claim and takes approval from TPA or your Insurance Company. Therefore, you have to follow up with the Hospital desk. The call centers of all Insurance companies are available 24×7. However, the Insurance desk at any hospital is open for a particular time period, in many cases, they are only open till 7 and completely closed on national holidays and festivals.

An Emergency or Contingency fund is highly needed in case of any emergency which could lead to a delay in the treatment. In many cases, the Claim approval is delayed but the patient needs immediate medical care. In such situations, one has to pay advance cash to the hospital which will be refunded later on. Therefore, it is very necessary to have an Emergency or Contingency fund for this purpose.

A patient is generally admitted to a hospital due to two types of situations:

1. Pre-planned
2. Emergency
   

In the case of pre-planning, one can submit all the necessary documents 2-3 earlier prior to admission in order for hassle-free and timely claim approval. This reduces rush and tensions amongst the insured or his family. In case of Emergency, one can hand over their respective documents to someone responsible and sincere who would take care of the situation.

In that case, those who have health insurance with roy’s Finance need not worry a bit as we have extremely dedicated persons who handle this section. Since it is managed by a dedicated and experienced professional, the approval time takes much less and is error-free.

Most of the time, the treatment begins with approval of a minimum amount and then the TPA is increased by the Insurance Company as needed. Hospital bills should be checked every day so that any kind of discrepancy could easily be sorted. If your policy has Capping Clause, Sub-limit, Co-payment Clause then the hospital will bill you accordingly and the payment has to be made in order to continue with the treatment.

Therefore, it is advisable to consult a professional (Book your free consultation at roy’s Finance) before choosing any policy that has Capping Clause, Sub-limit, Co-payment Clause under them. It is better if you choose a policy without these clauses. It is suggested to admit oneself to a hospital where cashless benefits are available. Moreover, one should always buy medicines from the hospital pharmacy which will be included in the cashless claim.

One needs to follow up with the pre-hospitalization and post-hospitalization costs even after claiming the cashless benefit by following the Reimbursement Claim procedure.

 

Reimbursement Process

When is a Reimbursement Claim needed?

1. From pre-hospitalization to post-hospitalization, the entire treatment can be done through a reimbursement claim.
2. If the cost of treatment is under a cashless claim policy, the pre-hospitalization and post-hospitalization expenses can be claimed through reimbursement.
3. It is even possible to claim a small amount through the cashless facility and the remaining through reimbursement.

If the treatment is pre-planned, one can submit the policy detail at the hospital 24-48 hours before admission to avail reimbursement. Even if it’s not pre-planned, one can inform the insurance company within 24 of admission. Reimbursement Claim Approval completely depends on documentation and record-keeping.

From the time of diagnosis till the recovery time, one submit all necessary documents, namely the doctor’s consultation fees receipt, prescription, test reports, X-ray, MRI, film if any, hospital bills, discharge reports, pharmacy bills, or any other relevant documents along with the claim form. The policyholder requires the insured person’s bank account details where the claim amount is deposited and a canceled cheque. These are submitted by the policyholder along with the KYC. It is advisable to keep the original and photocopy of each document and bill.

The following points need to be kept in mind – 

1. Keep a separate file to keep all the documents related to Health insurance. KYC, Pan Card copy, Aadhar Card copy, Photo, Copy of a Cancelled Cheque are to be kept in the same file. This particular file should be kept in a safe and secure place so that it could easily be found when needed.
2. If possible choose a hospital that supports a cashless facility.
3. One needs to be prepared if the policy has Capping and other clauses.
4. Keep two different files for Reimbursement Claim. Keep the doctor’s prescription, medical documents and test reports in one and use the other for all sorts of bills and receipts.