How to make a health insurance claim: All you need to know

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The process for filing a claim against your health insurance cover will depend on the type of policy you have taken. There are two main types of health insurance policy compensation plans and defined benefit plans. An indemnity-based plan pays the policyholder the actual expenses incurred within the amount insured in the policy. Whereas a defined benefit plan pays a predetermined, insured amount regardless of the cost involved.

Here’s how the claim process for these health insurance coverages works.

Compensation plan claim process

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Most basic medical claim policies fall under a compensation plan. “According to the name, indemnity-based health plans essentially reimburse the policyholder for hospitalization expenses up to the total sum insured,” says Amit Chhabra, Head of Health Insurance, Policybazaar.com. There are two ways you can claim against these policies – non-cash and payment patterns.

Non-cash medical claim process: A non-cash claim is the process in which the amount of the claim is paid directly by the health insurance company to the hospital. This facility is only available when you go to a hospital that the insurance company has a prior understanding of providing a non-cash claims service. These are called encrypted or networked hospitals that provide cashless claim service.

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However, a cashless plan does not mean that the policy holder will not incur any cost. There are some costs such as consumables that may not be covered by the policy; This needs to be paid by the policy holder. “If the insured opts for a cashless hospitalization plan, the insured only needs to pay a certain fixed amount and the insurance company takes care of the rest,” says Chhabra.

There are two types of non-cash plans depending on the nature of treatment in the hospital. “Planned hospitalization is done when you are aware that you will be hospitalized in the near future and you can obtain prior authorization from your insurance company before you are hospitalized,” says Nyan Goswami, Head of General Insurance, SANA Insurance Brokerage. This often occurs in cases of planned surgeries where you have sufficient time before admission to the hospital to obtain prior authorization.

However, in many cases, the insured may need to be hospitalized urgently. “Emergency hospitalization is when the insured experiences an accident or suffers from an illness that requires immediate hospitalization – an emergency,” says Goswami. In such cases, permission is requested after entering the patient.

“The basic claim process works the same for both individual corporate and personal plans. In corporate claims, it may help the organization’s HR contact the insurance company or TPA. Insurance brokers also provide assistance. But for a non-cash claim, they do not provide assistance. We really need Lots of intervention, and the hospital does most of the work,” Goswami adds.

While some insurance companies have their own claims processing arrangements with the hospital, many others have third party administrators (TPA) to coordinate their claim process with hospitals. In this case, you need to contact the hospital’s TPA help desk and show your health card along with the doctor’s advice for hospital admission. “They will fill out a cashless form that you may need to sign. Most of the form, the hospital will fill in, and you may need to fill in some personal details. The hospital’s TPA help desk will send the pre-authorization request to the respective insurance company for approval. Approvals usually take 30 minutes to 4 hours,” Goswami explains.

You need to carry any government ID like Aadhaar card, driving license etc. If the patient is dependent on an employee or policyholder, some hospitals may require proof of identity for the policyholder as well. Sometimes hospitals insist on the policy holder’s PAN card which is usually required when the amount of the claim exceeds 1 lakh rupees.

Payment status claims process: “Reimbursement claims are claims, where you pay your hospital expenses up front and ask for reimbursement from the insurance company after discharge. You can get reimbursement facilities at both network and non-network hospitals. You will need to submit bills and other documents (those transferred from your hospital at the time discharge) to your insurance company for reimbursement within 15 days of discharge from hospital,” says Goswami.

To make a reimbursement claim, there are different schedules given to the insured by insurance companies. “If a patient is going for their planned medical treatment, the policyholder must report the medical treatment and hospital details two days prior to admission,” Naval Goel, Founder and CEO, PolicyX.com, an IRDA-approved insurance comparison portal.

In the event that you do not find time to contact the insurance company due to an emergency, you should do so immediately upon admission to the hospital. “If the policyholder is admitted to an offline hospital in an emergency situation, the insured must be notified within 24 hours of admission and informed of the health status and claim,” Joel says.

In case this is not possible, you have a third option; You can do this after you are discharged from the hospital. “If the policyholder plans to file a compensation claim after hospital discharge, the claim should be filed between 7-15 days of hospital discharge,” Joel says.

How to claim reimbursement for pre and post hospital expenses

Most health plans cover not only hospitalization expenses but related expenses that occurred before admission to hospital and also after hospital discharge. “According to the regulations, the insurance company is required to reimburse the expenses 30 days before hospitalization and 60 days after discharge,” Joel says.

If your entire claim is through reimbursement mode, you can include these expenses while filing the claim.

However, if the hospitalization is non-cash, you may have to file this reimbursement claim separately. “Invoices for medical expenses related to the illness for which the insured was admitted to hospital should be submitted to the insurer or the designated TPA as per the terms and policies of the insurer. Post-hospitalization cost within a specified period,” says Rakesh Goyal, managing director of Probus Insurance Brokers.

Don’t forget to check the use of sublimation

Just having a higher insured lump sum may not be enough because many health plans come with lower scores for any medical condition. To avoid any last minute surprises, it would be a good idea for you to check if there is too much limit in your policy for the specific medical condition that requires hospitalization. “One should check for sublimation as it can reduce the amount of the claim. As there is a cap on specific conditions such as room rent, treatment of certain illnesses or post-hospital fees, the policyholder can only file a claim for the amount less than the minimum,” says Goyal.

In most cases, network hospitals will be able to keep expenses around this maximum but in the event of any complications or a longer stay, expenses may exceed the maximum. “If you know the sub-limit, it helps control expenses by ensuring that room rent is not exorbitant or treatment expenses are reasonable,” says Joel. If you have multiple policies, you can accordingly use another one to pay the additional expenses.

Time taken to get reimbursed for a reimbursement claim

The time taken to claim reimbursement is often on the higher side when compared to a non-cash claim that often occurs without a few hours. So to speed up the process, you need to file your reimbursement claim as quickly as possible.

“When the policyholder is admitted to an outsourced network hospital, he has to pay the full costs of the treatment. After discharge from the hospital, the policyholder can submit all relevant documents within 7-15 days,” Goyal says.

Once you submit a claim, it will take a few weeks for the insurance company to process your claim. However, on many occasions, the process of clarifying the queries raised by claims management can take a long time. “The whole process takes a maximum of 21 days to settle a reimbursement claim where the insurance company or TPA (i.e. path followed by the policy holder) verifies documents, reports, invoices, diagnosed reports etc. to the policyholder for clarification. If not, the claim will be settled within 21 business days,” says Joel.

Claim process for defined benefit plans

Major surgical benefit policies and critical illness plans are under defined benefit health insurance plans that pay a specified amount when an event such as a diagnosis of a covered illness occurs. Many life insurance companies also offer these health plans as a competitor to their life insurance policies. According to Kotak Life Insurance website, in the event of a critical illness claim, the passenger will be paid if the life insured is diagnosed with any of the illnesses as specified in the policy contract and if the claim criteria are satisfied with the passenger benefits.

Therefore, once the benefits of coverage are confirmed, you can file the claim after completing all the documents or you can inform the insurance company in advance of your plans to file the claim.

According to the HDFC Ergo website, in the event of a claim under Critical Illness Cover, you must immediately inform them of their helpline numbers. Upon receipt of the notification, the insurance company records the claim and assigns a unique claim reference number that is sent to the insured which can be used for all future correspondence.

According to the Kotak Life website, the mandatory documents that a beneficiary needs to submit to make a claim include a duly filled out Notice of Passenger Claim form, original policy documents, photo of the insured, proof of current address, photo ID proof, medical records that include counseling notes, treatment records, admission notes, and papers Hospital internal situation, discharge summary, investigation reports, etc. The insurance company may also request some supporting documents such as the life insured’s copy of the bank ledger or account statement with the bank account details.

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