Today expenses are on the rise and medical facilities are also following suit be it treatments or surgical procedures. For combating the medical expenses health insurance is very helpful. the primary purpose of having Health Insurance is to have financial protection in times of medical emergencies.
It helps in settling the bill for the treatment if the disease is covered under the said health insurance plan. However, the claim settlement process can be confusing if you're not aware of the correct procedures. To ensure your health insurance claim is approved and processed efficiently, it's essential to follow the right steps.
In health insurance, the claims are of two types namely: cashless claim or a reimbursement claim. The procedure for the claim settlement of both these types is different. Let us understand it in detail.
Cashless Claim Settlement
As the name suggests cashless claim settlement is a way in which the bill is settled by the insurance provider directly with the hospital. So, if your health insurance policy offers a cashless facility, following these five steps will help you settle the claim faster and seamlessly:
Verify Coverage and Network Hospitals
While purchasing a health insurance plan it is important to understand the terms and conditions of the policy especially the diseases and conditions covered, coverage as per your requirement, waiting period, network hospitals etc. Check and confirm that the hospital you plan to get hospitalised comes under network hospitals. This is because cashless claims can only be processed at network hospitals.
Inform the Insurer
It is important to inform the insurer about hospitalisation. In case of a planned treatment that requires hospitalisation ensure that the insurer is informed at least 48 hours in advance. In case of an emergency, the insurer can be informed within 24 hours of hospitalisation. Additionally, do not forget to submit the pre-authorisation form to the third-party administrator or the hospital. This pre-authorised form gives initial approval from the insurer to commence the treatment.
Provide Required Documentation
For cashless claim settlement the following documents are required by the insurer:
- health insurance policy
- Cashless Health Card
- Required KYC (Know Your Customer) documents to prove your identity.
- Doctor's recommendation for hospitalisation. In case of an emergency, the hospital's resident doctor of the emergency section shall provide this.
- The hospital will handle the rest of the documentation, and you will receive photocopies of the submitted documents at the time of discharge.
Maintain Records
It is important to maintain records of the treatment received at the hospital for future reference. Even though the hospitals share the documents directly with the insurance provider ensure that you obtain all the documents.
Claim Reimbursement for Pre- and Post-Hospitalisation Expenses
if your health insurance policy covers pre-hospitalisation and post-hospitalisation expenses ensure that you avail these expenses which may include ambulance charges, medication, lab tests, doctor consultation, etc. Submit the required bills and supporting documents to avail reimbursement.
Reimbursement Claim Settlement
As the name suggests, under this type of claim settlement you are required to pay for the hospital expenses upfront and then avail reimbursement of the same later. Here are 5 simple steps that you need to keep in mind to make the claim settlement process easy and quick.
Inform the Insurer
The first step is to inform the insurer about the hospitalisation. Under reimbursement claim, there is a specific timeframe within which all the documents must be submitted to the insurer to file a reimbursement claim. Failing to submit the documents within the prescribed time limit might result in claim rejection.
Gather the Required Documentation
Under reimbursement claims, it is important to gather all the relevant documents of treatment. Following is a list of essential documents required for filing a reimbursement claim:
- Health insurance policy card and details
- Insured's KYC documents (identity and address proof)
- Policyholder's bank account details with a cancelled cheque
- Doctor's recommendation for hospitalisation
- Original bills and receipts for all expenses
- Original diagnostic test reports
- Hospital discharge summary
Obtain a Fitness Certificate
This is one of the important documents that you need to submit to the insurer in case of a reimbursement claim. This certificate is issued by the treating doctor stating that the said treatment was correct and successful.
Maintain Thorough Records
In case of a reimbursement claim maintaining records of all the documents is very important as it will help you in resolving any discrepancy related to the same.
Claim Reimbursement for Pre- and Post-Hospitalisation Expenses
Unlike cashless claims, under reimbursement claim, one can file for reimbursement claim of hospitalisation and pre-hospitalisation and post-hospitalisation expenses together. Ensure you submit all the required documents to the insurer.
In a Nutshell:
Regardless of a cashless health insurance plan or a reimbursement-based policy, the claim settlement process is an important step. By following the above-given guidelines, you can ensure a smoother and faster claim approval process, reducing the chances of your claim being rejected.
Key Takeaways
- For a cashless claim, verify coverage, inform the insurer, provide required documentation, maintain records, and claim reimbursement for pre- and post-hospitalisation expenses.
- For a reimbursement claim, inform the insurer, gather the necessary documentation, obtain a fitness certificate, maintain thorough records, and claim reimbursement for pre- and post-hospitalisation expenses.
- Adhere to the specific time limits set by the insurer for intimating them about the hospitalisation and filing the reimbursement claim.
- Collect and retain all original documents related to your hospital stay, as they are crucial for the claim settlement process.
- Keep a file with photocopies of all the documents you submit to the insurer to ensure transparency and address any future discrepancies.
Thus, by understanding and following the correct procedures, your health insurance claim settlement process can be completed smoothly. Additionally, the above guidelines will help in minimising the chances of your claim being rejected. Remember, your health insurance coverage is designed to provide you with financial protection during medical emergencies, and you deserve to receive the benefits you have paid for. So follow the above process and be stress-free.
Recommended Read : Cashless and Reimbursement Claims in Health Insurance: A Step-by-Step Guide
