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National Health Insurance

Claim process of National health insurance

The National Health Insurance offers several beneficial health plans to its members that can be renewed throughout their lifetime. It is provided by the National Insurance Company Limited (NICL), which is owned by the Central Government of India. The following are the health insurance plans offered by NICL:

  • National Mediclaim Policy
  • National Parivar Mediclaim Policy
  • National Critical Illness Policy
  • National Mediclaim Plus Policy
  • Varistha Mediclaim Policy for Senior Citizens
  • National Individual Personal Accident Policy
  • National Janata Personal Accident Policy

The National Insurance Company has more than 1340 offices throughout the nation. Through its policies, the NIC aims to establish insurance as part of one’s financial discipline. NIC offers several Health Insurance policies for both individuals and their families to face the future with confidence and ensure financial stability.

Benefits of National Health Insurance

With the future being unpredictable, having health insurance is a great way to secure it. National Health Insurance ensures the protection of yourself and your family from illness that can jeopardize the health and financial condition. The following are a few of the benefits the National Health Insurance offers.

  • Cashless Facility - More than 6,000 hospitals around India offer various cashless facilities with the National Health Insurance
  • Tax Benefits - Eligible for tax exemption under Section 80D of the Income Tax Act of 1961
  • Online Renewal - Customers can buy and renew any National Health Insurance online
  • High Incurred Claim Ratio - The National Insurance has a high incurred claim ratio of 107.64% for the financial year 2018 - 2019
  • Responsive Customer Care - The National Health Insurance has a highly responsive customer care service, always up to solve your issues and queries

Claim Process of National Health Insurance

The best thing to do to claim the full benefits of the National Health Insurance is to contact the company as soon as a need arises. This would also speed up the cashless or reimbursement process. Read along to know how to claim your National Health Insurance.

Inform the National Health Insurance Company

You must contact the company as soon as the need arises. To process a claim for National Health Insurance, you have to contact the claim support directly. You can contact them on their toll-free number 1800 200 7710. Before calling, make sure you have the following details with you:

  • National Health Insurance card
  • Name of the policyholder
  • Policy number
  • Passport/PAN/Voter’s ID
  • Contact details

Claim Process for Cashless Treatment

To avail of the cashless treatment, you must be admitted to a network hospital. Visit the website of the National Health Insurance Company to access the full list of network hospitals.

  • If it is a planned hospitalization, inform the company or TPA at least 72 hours before the admission.
  • In case of emergency, inform the company or TPA after hospitalization of the individual but before completion of 48 hours.
  • Get a cashless request form the Preferred Provider Network (PPN) or Third-Party Administrator (TPA) or Insurance Company help desk at the hospital.
  • Complete the form and send it for authorization.
  • The TPA will issue a pre-authorization letter to the hospital once they receive the cashless request form, along with the medical details of the patient. After verification, the insurer will pay for the medical and admissible expenses directly to the hospital.
  • During discharge, verify and sign the discharge papers and pay for inadmissible and non-medical expenses.
  • After receiving and accepting the final documents, the company will pay to the network hospital within seven days.

If the patient fails to provide the required medical details, the insurer/TPA has the right to deny pre-authorization. In case the cashless treatment claim gets rejected, then the patient has to pay for the treatment and later claim for reimbursement.

Claim Process for Reimbursement Treatment

Even if your cashless treatment gets denied, there’s no need to worry. You can make a reimbursement claim to get the amount you paid for the procedure. To make a reimbursement claim, the insured individual must undergo treatment as per doctor’s advice. The individual has to bear all the expenses of the treatment.

  • Submit the documents within the prescribed time to the TPA or the insurance company.
  • After receiving the requested documents, you will receive the payment within 7 days, if the company accepts it.

If there’s a delay in payment, the company will pay 2% above the bank interest rate. The insurer/TPA has the right to deny pre-authorization if the patient fails to provide the required medical details. If the company rejects the claim, the same will be communicated to the individual in writing within 30 days of submitting the final documents.

Documents Needed for Reimbursement Claim

The following documents are required for filing a reimbursement claim:

  • Completed and duly filled claim form signed by the insured
  • Photocopy of the policy certificate
  • Photocopy of Identity proof
  • Original hospital receipts
  • Original Hospital discharge certificate
  • A detailed amount breakup of the charges incurred
  • Original payment receipts with prescriptions from the medical practitioner
  • Original investigation reports and bills with a note from attending doctor or surgeon
  • Original certificate from the surgeon stating the nature of operation performed, along with the bill and paid receipt
  • Attending doctors’ or specialists’ bill, receipt and certificate
  • Other documents if requested by the company or TPA Charges Covered by the National Health Insurance Policy
  • Expenses for treatment including doctor consultation fees, surgeon’s fee, anaesthetist fee, and specialist doctor fee up to the specified limits.
  • Hospital room rents up to 1% of the insured amount, provided it is not more than Rs.5000 per day
  • ICU room rent up to 2% of the insured amount, provided it is not more than Rs.10,000 per day
  • Expenses for medicines, nursing, operation theatre, operating expenses, blood, and oxygen
  • Specialized medical treatments such as Chemotherapy, Radiotherapy, and organ transplant up to the specified percentage of the policy amount
Charges Not Covered by the National Health Insurance Policy

While the National Health Insurance covers all medical expenses and applicable charges, there are certain charges that the policy won’t cover. The following costs are not covered under the National Health Insurance policy:

  • Charges incurred during hospitalization for diagnostic purposes
  • Expenses incurred due to medication or hospitalization for drug overuse, alcoholism, congenital external diseases, venereal diseases, or intentional self-infliction of injury
  • Expenses on dental treatments
  • Expenses on childbirth treatments
  • Expenses on the treatment of HIV disease

National Health Insurance is one of the best health insurance policies in the country and offers several customized insurance plans. You can apply for your policy online. It is always better to have a health insurance policy as it would safeguard your future.

Recommended Link:Difference between National Insurance Parivar Mediclaim and Mediclaim Policy