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Are Health Insurance Claims Time Bound?

Rohit Sapra Rohit Sapra 03 October 2017

We all have grown up hearing, “Time and Tide Wait for No Man”, well today the Health and General Insurance Companies have started implementing this very strictly with regards to your Health Insurance claims. It seems like they are telling us, file your Health Insurance Claims on time or kiss them good bye.

Health Insurance Claims

The question is should you be worried about it? The honest answer is “YES” in bold capitals, after all we are talking about your hard-earned money and the very purpose of buying a health insurance plan.

You have bought a health insurance plan for yourself and your family members with the sole purpose of protecting your hard-earned money from medical expenses. If your claim becomes unacceptable, the whole exercise of buying a health insurance plan gets wasted.

So, what is the time limit for filing a Health Insurance Claim?

A health insurance plan benefits can be claimed by its policyholder in two ways:

  • Cashless Treatment Facility – For availing cashless facility you have to do inform the insurer about the planned hospitalization 48 or 72 hours in advance (depending on the insurer). In case of an emergency, the insurer has to be informed within 24 hrs after hospitalization. For availing cashless treatment all you have to do is:
    • Visit the network hospital and present the health card along with a valid photo identification proof.
    • Fill the Pre-authorization Form and send it to the insurer (TPA, if applicable).
    • The health insurer sends an authorization to the network hospital to proceed with the treatment.

Now all you have to do is get yourself admitted to the hospital, relax and get well soon. The network hospital will submit all the original bills, treatment reports, discharge summary, etc. to the insurer.

However, it is very important to keep a copy of all your treatment related bills and other medical documents. You never know when they might come in handy.

  • Reimbursement Facility – Under this, the insured person has to fill for a reimbursement claim with the insurer to get back the eligible amount spent by him/her on respective treatment covered in the health insurance plan.

A reimbursement claim has to be filed within 15 days of receiving discharge from the hospital with the insurer. The insured has to submit a duly filled and signed claim form and a copy of photo id of the insured and originals of the following documents:

  • Final bill from hospital
  • Hospital bill payment receipts
  • Breakup of the hospital bill
  • Discharge summary
  • Operation theatre notes
  • Indoor case papers
  • Ambulance receipt
  • Certificate from attending doctor
  • Medical reports and prescriptions
  • Medicine bills and prescriptions
  • First information Report, final police report, if applicable

However, insurer may accept the reimbursement claims beyond the stipulated timelines on humanitarian grounds only if the reason for the delay in submitting the reimbursement claim is valid, genuine and acceptable.

I am sure you would be thinking, “Why the insurers are giving such a short time for filing the claims?”

The answer is pretty simple and straight forward, insurers want to weed out Fraudulent Claims. Sooner the insurer comes to know about a particular claim, the faster they can contact the doctors and begin their investigations. Insurers are of the view, if a considerable amount of time is given between discharge from the hospital and submission of reimbursement claim, fraudsters can cook up fake documents and submit exuberant claims. Such fake claims will have a negative impact on an insurers performance.

But then again, a question arises, “What will happen to my Post Hospitalization Claims?”

Insurers have already factored this, you can submit Post hospitalization bills within 15 days after completion of 60 or 90 days period (whichever is applicable based on the insurer) from the date of discharge from hospital. Thus, they are trying to create an environment acceptable to everyone.

So, let's put out reminders and post-it notes on our health cards and policy documents about the time limits on filing health insurance claims, after all nobody wants to run around the insurer asking for an extension and explaining reasons. Even worst, we do not want our hard-earned money to get wasted if insurer refuses to accept our claim for being submitted beyond the stipulated time.

Recommended Read: Need of Medical Insurance

Rohit Sapra
Written by Rohit Sapra
Rohit Sapra, a licentiate, and currently an SME, is a seasoned insurance professional with previous work experience from Kotak and Birla Sun Life Insurance.