Navigating health insurance claims– A step-by-step guide

Healthcare costs are increasing rapidly, so investing in a good Mediclaim policy can save you from financial setbacks, especially during expensive medical procedures. In addition to hospital bills, a comprehensive health plan covers pre- and post-hospitalisation expenses, home healthcare, daycare procedures, alternative treatments and other healthcare expenses. Moreover, if you choose a network hospital for a medical procedure, you can opt for cashless treatment without worrying about settling the bills from your pocket. If you have little or no idea about health insurance claims, we will tell you in this article.

Health insurance claims

There are two types of health insurance claims – cashless and reimbursement.

1. Cashless claims: If you choose a network hospital for your treatment, you can file a cashless claim with the insurance provider. Network hospitals are the hospitals and diagnostic centres with which your insurance provider has tied up. You can find the list on your insurer’s website and policy documents.Cashless claims are settled directly by the insurance provider, so you won’t have to pay the bills from your pocket. Thus, the claims are settled with minimum documentation.?
2. Reimbursement claims: If you opt for medical treatment at a non-network hospital, you must file a reimbursement claim with the insurance provider. In this case, you must settle the bills from your pocket at the time of discharge and then claim a reimbursement of the expenses by submitting your medical bills and receipts to the insurer. Insurance companies usually settle reimbursement claims within 3 to 4 weeks of receiving them.

Steps to file a health insurance cashless claim

For a cashless claim, you can select a network hospital of your insurance provider and follow the steps below —

• Step 1: Intimate the insurance company about your hospitalisation. If it is a planned procedure, you must inform them at least 72 hours in advance or as mentioned in your policy documents. Medical emergencies should be intimated within 24 hours of hospitalisation.
• Step 2: On the day of hospitalisation, carry your health insurance cashless card and a valid photo ID proof to the hospital. Show them at the TPA desk or hospital insurance desk for verification.
• Step 3: Take the pre-authorisation form from the hospital TPA desk, fill it out correctly, and submit it back at the TPA desk for verification.?
• Step 4: The TPA will check your health insurance details, such as policy sum insured, coverage, and add-on covers, before approving your cashless claim.
• Step 5: If everything looks fine, the TPA will approve your claim for cashless hospitalisation, and the insurer will settle your medical bills directly with the healthcare establishment.

There can be instances when the TPA rejects cashless claims. If you face a similar situation, you can file a reimbursement claim with the insurer. For this, you must settle the hospital bills from your pocket at the time of discharge and then claim reimbursement of your medical expenses within 7-15 days.

Steps to file a health insurance reimbursement claim

If your cashless claim gets rejected or you choose a non-network hospital for a medical procedure, you can file a reimbursement claim with the insurer by following the steps given below —

Step 1: Inform the insurance provider

Inform the insurance company about your hospitalisation at least 72 hours in advance or within the deputed timeline. If it is a medical emergency, inform them as soon as possible, but not later than 24 hours of admission to the hospital.

Step 2: Collect the medical documents

While getting discharged from the hospital, collect the discharge summary and other bills and receipts of the medical expenses incurred during hospitalisation. You must submit the following documents while filing a reimbursement claim —

• A valid photo ID proof
• Your health e-card
• Original discharge summary
• Medical certificate or doctor’s prescription recommending hospitalisation
• Doctor’s consultation slips
• Doctor’s prescriptions for diagnostic tests
• Diagnosis reports of blood tests, X-rays, etc.
• Prescriptions for medicines
• Original pharmacy bills
• Original receipts from the hospital
• Ambulance receipt, if applicable
• FIR, in the event of an accident

You must submit original bills and documents to the insurance company, all duly signed and stamped. Remember to keep photocopies of all for your records.

Step 3: Submit the claim form

Get the claim form from the insurance provider or TPA at the hospital. You can also visit your insurance provider’s website and download it online.?

Fill out the form correctly and sign it before submitting it to the insurance provider. Attach the supporting documents as well for verification. You must also submit a cancelled cheque of the bank account in which you want to receive the claim amount.

Step 4: Claim verification

The insurer will verify the claim form and documents before accepting or rejecting your claim. If everything looks fine, they will approve your claim and reimburse the amount to your bank account.

Things to keep in mind to avoid claim rejection

The following are some important points to keep in mind to avoid health insurance claim rejection —

1. Be transparent about your medical history: When filling out the health insurance application form, be transparent about your medical history and current health status. Inaccurate information can lead to the rejection of your health insurance claim.
2. For example, if you are buying health insurance for senior citizens, mention the pre-existing conditions they are suffering from in the insurance application form. Although this may increase their policy premiums by a small percentage, being transparent about their health status can prevent claim rejection.
3. ?Check policy coverage: Insurance companies entertain claims only for those medical issues and procedures that are covered under the policy. Hence, before you file a claim, check policy inclusions, exclusions, sub-limits, deductibles, copayments, etc., carefully and file a claim accordingly. Meeting all policy terms and conditions can help you avoid claim rejection.
4. Inform the insurer: Be it a cashless or reimbursement claim, you must inform the insurance provider about your hospitalisation within the stipulated timeline.?
5. Certain treatments and procedures may require pre-authorisation, so make sure you check the same in your policy documents and obtain approvals from your insurance provider in advance. If you fail to do so, the insurer may reject your claim.
6. File claims correctly: When you buy a health plan, familiarise yourself with the claim filing process to avoid associated hassles later. Fill out the claim form correctly and submit all supporting documents with it.?
7. Submit claims promptly: If you choose a non-network hospital for medical treatment, file a reimbursement claim within 7 to 15 days of getting discharged from the hospital or as stated in your policy documents. Although insurance companies cannot deny genuine and verified claims on the grounds of delay alone, they may have to reject them if the delay is too long.
8. Seek assistance: If you have a query or need help while filing a health insurance claim, get in touch with your insurance provider’s customer service representatives. They can answer your queries and walk you through the process, making it a breeze.

FAQs

Why is health insurance important?

A healthcare policy can cover your medical bills and reduce your financial burden. Also, with a health plan handy, you can opt for quality and timely treatment without worrying about paying huge bills from your pocket.

How do I avail of cashless treatment?

You can avail of cashless treatment at any network hospital of your insurance provider. You can check your policy documents or the insurer’s website to learn about the network hospitals in your city of residence.

What should I do if my cashless claim gets rejected?

If the TPA rejects your cashless claim, you can file a reimbursement claim with the insurance provider. Make sure you submit all supporting bills and documents along with the claim form. Also, try to file the claim as early as possible to avoid claim rejection and associated financial woes.

How many health insurance claims can I make during a policy period?

You can make multiple claims during a policy period, as there is no pre-decided cap on this. However, you can make claims only up to the sum insured by your health plan. Once you have exhausted the sum insured, you can’t make more claims during the policy period.

What is the timeline for the settlement of a reimbursement claim?

In most cases, insurance companies settle reimbursement claims within 3-4 weeks of receiving them. However, you must follow up on the status of your claim from time to time to avoid delays.

Conclusion

A health insurance or Mediclaim policy offers much-needed financial support during medical emergencies and planned hospitalisations. If you undergo treatment, you can file a claim with your insurance provider and save yourself from paying the bills from your pocket. However, make sure you file claims correctly and promptly to avoid rejection and associated financial setbacks.?