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The Ultimate Cheat Sheet on Health Insurance Claims

Health insurance is aimed to protect us financially against any unfortunate hospitalization and related expenses. Isn’t that the reason why we invested so much time and efforts in choosing the right plan and continued to pay the premiums year after year? However, regardless of this, there’s still lack of awareness about how to claim on your health insurance.

Pathway to Successful Health Insurance Claims

Your health insurance policy can be claimed in two ways:

  • Cashless Settlement: Every insurance company has network of hospitals that form a part of its PPN (Preferred Provider Network). When you wish to get treated in any of such hospitals, you are entitled for a cashless treatment where the insurance company/Third Party Administrator settles the cost of hospitalization and subsequent expenses directly with the hospital without involving you.

  • Reimbursement of Medical Expenses: In situations, where you are unable to get treated at a network hospital, you can opt for the hospitalization and the subsequent treatment in your choice of hospital, pay for the same through your pocket and then claim for reimbursement. In view of the huge costs involved that you need to bear at the time of discharge from the hospital, this may not appear to be a preferred choice for many.

How to Claim Health Insurance?

Every insurer has laid down few procedures to enable hassle free claim process. Hence, it’s important to be aware of these processes to avoid any eleventh hour surprise. Please refer the following for raising successful claims.

For Cashless Settlement

  • Intimate the insurance company at least 1-2 days in advance in case of planned hospitalization. An intimation should be sent to the insurance company within 24 hours, if it’s an emergency hospitalization.

  • Most network hospitals have a dedicated TPA (Third Party Administrator) helpdesk that assist the insurers with all the necessary documentation and formalities. Hence, it’s significant to contact the TPA desk to fill the claim form and submit the necessary documents like health card, doctor’s report, etc.

  • Once these documents are received by the insurance company/TPA, they are scrutinized to check against the policy coverage and terms.

  • If within the scope of coverage, an approval is sent to the hospital for a specific amount. Should the cost of treatment exceed the approved amount, the hospital can request for the re-approval.

  • If the request for cashless treatment is denied, one can pay towards the hospitalization and treatment from his own pocket and then raise the request for reimbursement.

For Reimbursement of Claims

  • As in cashless settlement, an intimation to the insurance company is mandatory even if you wish to go for reimbursement way.

  • After the hospitalization post necessary treatment, you have to submit the necessary documents to the insurance company/TPA to kick-start the process. Following documents must be submitted to enable smooth processing:

    • Duly completed claim form
    • Discharge summary signed by the treating doctor/hospital
    • All medical bills along with the related prescriptions
    • As per the pre-post hospitalization cover clause in your policy document, you can also submit the expenses/OPD costs related to the hospitalization sought
    • Copy of cancelled cheque
    • Any other necessary documents on the request of the insurance company
  • Post scrutiny of your claim request and the documentation you submit, your claim will be accepted/denied basis the policy terms and conditions.

  • If your claim is accepted, the final amount is disbursed along with the Claim Settlement Letter specifying the break-up of the amount.

  • If the claim is denied on valid grounds, Claim Rejection Letter will be shared with the insured stating the reasons for the same.

Must Read: Things to do when your Health Insurance Claim gets Rejected

Few Pointers

  1. To claim on your health insurance, a minimum of 24 hour hospitalization is mandatory.

  2. When you receive the policy documents, please refer the policy wordings for the terms and conditions related to your plan including the process to follow in case of claims.

  3. Every insurance company has set certain time frames to follow in case of various processes. Ensure to follow them to avoid any surprises.

  4. Be aware what’s covered and what’s not in your health insurance plan. More than what’s covered, it’s important to pay close attention to what’s not.

  5. Share a copy of your policy documents, health card and contact details of the insurance company/TPA with your family, friends along with the process to follow in case you are in no position to follow the procedure yourself.

  6. Keep an eye on the waiting periods for claiming on your insurance policy.

  7. Last but not the least, ensure you maintain a proper file with all the prescriptions, medical bills, etc. for easy availability.

Why Coverfox Should Be Your Ideal Choice?

Coverfox, being an IRDAI certified broker, is well equipped to handle all your queries and concerns regarding claiming on your health insurance policy. We can be your ultimate choice with the below services on offer:

Claim Intimation: We can intimate the claim to the insurance company on your behalf saving a lot of your valuable time and efforts.

Documents Pick-Up: We can arrange to pick up all your claim related documents from your home/office as per your convenience.

Documents Scrutiny: We have dedicated and qualified Claims Team who thoroughly scrutinize your documents for correctness or any missing information before submitting them to the insurance company/TPA. This saves a lot of your time in back and forth coordination with the insurance company/TPA. The team can also provide a rough estimation of the claim amount that you can expect to get compensated for.

Follow-Up and Status Update: We understand your anxiety when it comes to claiming on your health insurance. Therefore, we keep you posted with all the updates related to your claim assuring complete peace of mind. Similarly, we follow up with the insurance company/TPA for the timely disbursement of the claim amount.

Dispute Resolution: At last, we will be there for you at the most crucial time – when you really need us. In case you are not satisfied with the outcome of your request, we will raise the same with the insurance company and if required, also help you dealing with it through grievance cell.

Frequently Asked Questions

I have just bought a health insurance plan. Am I entitled for the cashless treatment?

Every health insurance plan entitles for the cashless treatment provided you seek it in a hospital that is within the network of the insurance company. As mentioned earlier, a minimum of 24 hours of hospitalization is mandatory to claim on your health insurance.

What if the insurance company deny my request for cashless treatment?

As per the IRDAI guidelines, no insurer can deny your valid claim. Hence, if your request for the cashless treatment is denied due to valid reasons, you can still pay towards the treatment and all related expenses through your own pocket and then raise the request for reimbursement. If your claim request is within the scope of coverage as per the policy terms and conditions, it cannot be rejected.

What are the charges/expenses that are not covered in the health insurance?

There are certain expenses that are not covered in any health insurance plan such as administrative charge, services charge, expenses related to laundry, extra bed, toiletries, diapers, syringes, telephone charges, etc. For detailed information on what’s not covered by your insurance company, please refer the policy wordings.

Is there any waiting period to claim on my health insurance?

Typically, every health insurance policy is bundled with three types of waiting periods.

  • The initial waiting period: This specifies to an initial 30 days of waiting period where you cannot raise a claim on your health policy except in case of an accident.

  • Ailment specific waiting period: There are certain ailments that are covered by the health policy only after a certain waiting period such as two years. This list varies as per insurance company and is mentioned in the policy wordings.

  • Pre-existing Disease waiting period: Most insurance companies cover the pre-existing diseases after a waiting period of 3-4 years. Hence, if you have specified any illness as pre-existing during the time of policy purchase, the same will be covered only after the waiting period mentioned in your policy.

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