Health insurance-how to make a claim

Most of the policy holders of health insurance are unaware of how their health policy actually works and their knowledge remains mainly limited to value of sum assured under the policy. Even they are not aware what are hospitals covered under it within their arena. In such a scenario, when a possible Hospitalization comes into play , most of the policy holders remain confused what needs to be done and how to get optimal benefit out of policy. They end up in learning lesson losing the claim in their maiden attempt.

It is better to understand the process involved the moment one of the member covered by policy step out of the home to be hospitalized for medical treatment. Most of the current health insurance policies provide cashless hospitalization whereby all expenses are directly routed by the insurer to the hospital.In certain cases, it is some percentage sharing like 20% by insured and rest by insurer when the policy covers aged people. This type of insurance ensures that we do not have to arrange for any payment/full payment from our own pocket except for non-admissible bills.

At the commencement of insurance cover, once we receive the health card (for all members) and the member booklet, we should go through the cards for any discrepancies as this will create problem.If any discrepancy exists in the name of the insured or commencement of cover etc or insured value,then the same has to be brought before the insurer or his third-party administrator(TPA). Then we should read the guidebook in details with the various services offered by TPA and how to avail it. Also we should study about the details of exclusions specified in the policy. This will help to know for which are diseases we can get cashless treatement or subsidized treatement. It is better to identify the nearest hospital in the nearest locality to the residence for typical problems like ortho, Eye, Heart, ENT or Multi-service hospitals which is covered by TPA and note down their telephone number and also ambulance number of the said hospital. This is one time pain for remaining calm when emergency arises. Even involving spouse will be better option as insured may remain in office when any emergency cropped up.

There are three methods for getting payment from insurer.

Flow chart-1 ( Hospitals recognized by TPA )

a. Planned hospitalization:
1.The TPA has to be informed about hospitalization within specific number of days as specified by policy documents.
2.At the time of admission, hospital verifies the Health card of the insured and admitted person with his valid photo ID. The policy document, health card and the guidebook are important documents which should be kept in safe custody and they must be carried when any one gets admitted in the hospital. So it is better to spend some time for this to avoid last minute search at the time of emergency.

3.Once admitted in the hospital, we have to fill up necessary forms and documents specifying the ailment, disease or accident etc. for which treatment is required.
4.Then we have to forward necessary documents to the insurance company through TPA which will include the estimate of costs involved in the treatment.
5.On receipt of the documents, the insurance company/TPA will screen the documents and sanction the claim resulting in cashless hospitalization/major cashless hospitalization as per the policy agreed for the insured. If they are not satisfied with the documents, they may seek further documents/queries to the insured which we should provide satisfactorily upon which
they will give sanction. In this case insurance company will pay for all covered and approved bills directly to hospital and ineligible bills not covered has to be paid by insured to hospital. The insured has to sign all documents for which insurance company pays for him at hospital site.

If they are not satisfied, they can reject/deny the cashless hospitalization claim of the insured thus making the insured to pay for the hospital expenses. The rejection letter is called decision letter which provides reasons for rejection of the claim.

6.Insured person can get reimbursement for the expenses that are incurred after the discharge from hospital and covered by policy if such expenses are covered under post-hospitalization expenses.

b. Emergency hospitalization:
Every thing is same as above except that TPA/insurance company has to be informed within 24 hours of admission in the hospital covered by policy.

c. Claims procedure for reimbursement in case of admission in hospitals other than approved one:
The insured gets the treatment in the private hospital and pays the bills. He informs the TPA about the treatment he/family members are taking from hospital before discharge from hospital. The original documents are received by the insured after payment from hospital. Then the insured person fills up the required documents like claim settlement form etc. and submit
them along with the original bills/documents like prescription, discharge certificate etc. to the TPA/insurance company for reimbursement of claim.

Normally the following documents are insisted by insurance company:
1.Claim form duly filled in.
2.Photocopy of ID card and health card.
3.Photocopy of the policy documents.
4.Original hospital bills.
5.Medicines outside hospital purchased based on prescription from the hospital doctor.
6.Original discharge summary report.
7. All original investigation reports or photocopies of the same attested by hospital.

It is better to take a copy of the documents submitted for future reference. The TPA/insurance company will check the bills of claim and accept the claim if it adheres to policy terms. It will send the cheque to the insured for the claim amount and if any disallowance is made, the same may be informed by insurer. TPA/insurer may require more details if necessary and the same has to be submitted by the claimant for payment. If the claim is not as per terms of policy, the insurance company reject it and reasons will be given in the decision letter sent to insured.

My old article for health insurance part I and Ii also can be seen.

C.R. Venkata Ramani


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