How to get claim on health insurance
Medical insurance helps us in overcoming financial difficulties and hiccups. But what would you do if your insurer refuses to pay your claim or is delay-dallying the same. At Policybazaaar we help you solve this mystery called the claim refund process in healthcare insurance.
In a typical insurance firm the TPA/insurance firm has to be informed when you are going for admission in a network hospital. If there is an emergency you can inform as soon as you are able to get time. The idea is to keep the insurer in loop. Once the claim documents are submitted, the insurance company/TPA checks the documents and if satisfied provides the insurance amount to the claimant.
There are several steps you can take to ensure a smooth claim process:
Read the policy wording carefully before buying the policy: Although a much harped message, many of us actually rely on the words of the company representative or agents while choosing mediclaim policy for family. The policy documents will be the only legal document you would be having in case the insurer decides to deny your claim. Hence, its important to read and go through it carefully before you sign on the dotted line. Take a special note of the exclusions while you compare healthcare plans as mostly it’s the exclusions which form the base for legal disputes later.
Get the claim form: contact your insurance company and get the claim form as soon as you can find time. The claim form will be asking about your information, your insurance information, what was the incident (accident/disease), the doctor and hospitals name, etc. Make sure you fill all the details correctly. Regarding questions such how you need the payment and on whose name the payment should be made, make sure you give proper details and name. If you have any other information, expenses, etc mention the same in the claim form. If there is no space to mention the same take a white sheet of paper and mention the same. We suggest whether you are buying a individual health insurance plan or family floater plan, keep claim forms handy with you even if the need has not arisen as yet.
Filling the claim in time: Insurers prefer the claim to be filed within 15 days. Many times there are details which cannot be traced if the information have reached the insurer late. For example, in case of an accident, tyre tracks might be erased if the information reaches the firm late and this can be cause of your claim getting delayed or worse repudiated.
Preserving all the documents: If you have gone to a non-network hospital this is a must. Even if you have gone to a network hospital make sure you preserve all the medical bills, prescriptions, receipts, etc. If your hospital denies giving a bill, demand it. While submitting the documents to the insurer make sure to keep a Photostat of all the documents submitted.
Get legal help if the insurer is sitting quite on your claim: In most of the cases, no legal action may be taken against the company prior to 60 days after the proof of loss has been furnished or more than three years after the date proof of loss is required to be furnished. Hence, don’t just wait for an answer from the insurance firm. Give them time to sort out any documentation issues, but in case the time being taken is more than required try and get legal help.
Remain calm: Even if the insurance company denies your claim you need not panic. Don’t take the first denial from the claim insurance as the final answer. Usually a denied medical claim can take a lot of time and will need your perseverance and patience for the same. Ask them the reason for denial of the claim. In response, gather the facts and proofs in form of documents and re-read the policy wordings. If you are unable to understand certain terms and conditions, get help from someone. If the company still denies the claim on shallow grounds you can always file a complaint with consumer courts or IRDA to sort out your claim related issues.