Health Insurance Claim Process -Everything You Need to Know
Updated On Apr 06, 2024
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Today, with the phenomenal upsurge in the expenses involved towards the medical treatments and succeeding procedures, investing in a good health insurance policy is no longer a choice. To be able to enjoy that peace of mind and a much desirable monetary respite, in times required, one has to have a well-meaning health insurance cover for self and all those loved ones around. And if you have already purchased a worthy health insurance plan, claims settlement is one area you are duty-bound to be conversant with for easy dealings, whenever essential. This article will take you through a 5 step process for convenient claim settlement on your health policy.
Health Insurance Claim Process
Types of Claim Settlement:
- Cashless Claims
- Reimbursement
Cashless Claims – Steps to follow
If a planned hospitalization is summoned, you can opt for a cashless settlement. Below are the steps you need to follow for a convenient process.
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Step 1
Check: Whenever you wish to opt for a cashless hospitalization, you need to check the two important things. Whether the ailment is covered as per the Terms and Conditions of your health insurance policy. Whether the hospital is in the network tie up of the insurer Therefore, a phone call to your brother or the insurance company helps before you go ahead with the hospitalization.
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Step 2
Intimate: Whenever you wish to claim on your insurance policy, it's utmost important to intimate the same to the insurance company; either cashless or reimbursement. At the hospital, during admission, you will be asked to fill a Pre-Authorization Form and submit the same at the TPA (Third Party Administration) counter. They will further forward the form to the insurer for the cashless approval.
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Step 3
Documents Submission: At the TPA counter, you will be required to submit the documents like the Cashless Health Card provided by your insurer along with certain KYC documents for identity. They might take a copy of the same and return the original documents.
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Step 4
Record Keeping: Once the cashless approval for the claim is received from the insurer, your original documents pertaining to the hospitalization will be retained by the insurer. Hence, it’s advisable to ask for a copy of the same for your records.
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Step 5
Pre-Post Hospitalization: Check about the pre and post hospitalization cover in your health policy. You will need to retain the bills and all associated prescriptions/medical reports to claim the same. This claim is always done on reimbursement basis. Kindly refer to the Policy Wordings for the timeframes related to the same.
Reimbursement Claims – Steps to follow
Some plans do not provide a cashless claim facility and you have to reimburse the expenses. Reimbursement may also be sought if you seek treatment in a non-network hospital or if you fail to opt for cashless settlement. Whatever be the scenario, the following steps are to be followed in case of a reimbursement claim –
Step 1- Inform the company and submit the duly filled reimbursement claim form available with the insurer within 30 days from the date of discharge from the hospital.
Step 2- Attach all the original copies of the medical reports, medicine bills and hospital bills duly stamped and signed with the claim form. The hospital bill should clearly mention the Registration No of the hospital. The reports should also clearly mention the name of the patient and date and should be attached along with the prognosis prescription of your doctor who advised on hospitalization to show that your hospitalization or medical prescriptions was not voluntary but as per your doctor’s advice.
Step 3- After your discharge from the hospital, it will issue a Discharge Summary/Card which claims that you were fit to be discharged. This Card is to be submitted to the insurer.
Step 4- Your doctor’s follow-up prescription which shows your fitness after hospitalization is also needed to be submitted in original. For post hospitalization expenses, you can submit the bills within 60/90120 days from discharge, depending on the terms of your insurance policy.
Step 5- You should retain the copies of all submitted documents for future reference. Your claim will be settled within 2-3 weeks after the claim is registered.
Conclusion
Your health insurance plan will prove useful only if you are able to successfully claim for your expenses. Following these steps will ensure you of a valid and speedy settlement of all your health insurance claims.
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