How to Claim Health Insurance Peacefully?

Health Insurance Claims

When you are feeling, a claim for health insurance, you need to remember certain things, to make sure you do not face any rejection from the insurance company.

Health Insurance Claim Settlement is the process of claiming your health insurance policy benefits from the insurance company. When you buy health insurance, it comes with a cover in the form of a sum insured. The sum insured is utilized to provide financial aid in case of emergency/accidental hospitalization/medical treatment costs.

How do you utilize your sum insured? By making a claim directly with your insurer. Upon successful registration of your claim, the insurer will accordingly reimburse the cost of medical treatment incurred.

For example, Mr. A met with an unfortunate accident for which he was admitted to the hospital for 48 hours. The cost of medical treatment, doctors’ fees, and the hospital bill came up to Rs. 1 lakhs. Since Mr. A has a comprehensive health insurance coverage policy of up to Rs. 5 lakhs sum insured, he can quickly settle this claim with his insurance company. Under this process, the amount of Rs. 1 lakh will be compensated to Mr. A by his insurance provides, as per the policy cover.

As mentioned above, the two most common methods of making a claim are via cashless or reimbursement mode.

What are the Types of Claim Settlement Options?

There are two types of claim settlement options:

Cashless Claim Settlement Option

A cashless claim option can only be availed if you are admitted to a network hospital, as mentioned in the policy document. Your policy document has a list of network hospitals in your city of residence. With the cashless mode, you need not pay a single amount from your wallet. The insurer will cover the entire cost of hospitalization and medical treatment. All you need to do is furnish your cashless health card to the third party administrator.

Reimbursement Claim Settlement Option

Under this option, you will be required to pay the hospital bill and cost of medical treatment to the hospital, immediately post-treatment or before discharge. Then you need to file for claim reimbursement directly with your insurer. The insurer will reimburse the cost of treatment as per the policy wordings.

What are the Documents Required for Claim Settlement Process?

All the listed documents should be original:

1. Claim application Form - Duly filled and signed

2. Doctors’ prescription

3. Treatment papers

4. investigation/diagnostic reports/X-Ray

5. Original medical bills and scripts

6. Invoice for medicines

7. Hospital discharge card

8. Copy of FIR in case of an accidental emergency

9. Copy of Health Card

10. Cancelled cheque

11. KYC - PAN card and Hospital Registration Card

12. Consultant’s certificate with diagnosis (including the date when symptoms first occurred)

13. Relevant Investigation reports (Radiology, Pathology, etc) confirming the diagnosis

14. Certificate from attending doctor/physician stating the condition of the patient

How to Make a Health Insurance Claim?

Claim settlement process via cashless mode/pre-planned:

1. Visit the network hospital of your choice

2.Submit your cashless card at the TPA

3. Fill the Cashless Request Claim Form and submit the same to the TPA

4. Ensure that you have a relevant photo ID and policy number

5. Submit the relevant documents required for treatment

6. The TPA will coordinate with your insurer for a pre-authorization form

7. Post verification, the insurer will grant the precision for covering the cost of treatment meant

8. Make sure you take all the records of your treatment and hospital bills

In the reimbursement mode case, you will be required to clear the hospital bill from your own pocket. Later, when you are discharged, you will have to file a reimbursement claim with your insurer along with the relevant documents. Post submission, your insurer will process the claim accordingly and reimburse the treatment cost straight to your account.

Can My Claim Get Rejected?

Yes, here are the instances under which your claim can get rejected:

1. Any fraudulent claims

2. Claim under an expired policy

3. Treatment that is not covered under the scope of cover

4. Treatment within the waiting period

5. All types of general and standard exclusions

In Simple Words,

When you are looking to buy a health plan, ensure that you go for a company with a high claim settlement and incurred claims ratio.