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Useful Tips for Speedy Health Insurance Claim Settlements
Investing your hard-earned money into a health insurance policy so that you protect yourself and your family from any financial burden in case of medical emergencies is the most prudent course of action. A health insurance policy is a must for every individual in this modern day life because of the rising incidence of illnesses and the corresponding rising trend of medical costs. In such a scenario, you should insure yourself with a sufficient amount so that the claim does not burn a hole in your pocket.
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- Useful Tips for Speedy Health Insurance Claim Settlements
Even after availing optimum health insurance coverage, we still fear the claim scenario almost always expecting one or more hassles at the time of settlement. Our fears are reasonably justified because the health insurance claim settlement process, unless otherwise known, can be a cause of concern. Therefore, simply buying a health plan is not enough; you need to also know the claim settlement process of your policy to avoid future hassles. So, let us take a look:
Types of Claim Settlements:
There are two ways in which your claim can be settled namely -
- Cashless - This is by far the easiest settlement process. Under the process, if the policyholder gets admitted in a network hospital referred technically as the Preferred Provider Network (PPN), all expenses are directly settled by the insurance company through Third-Party Administrators (TPA) who act as an intermediary between the hospital and the insurance company.
- Reimbursement - Under this process, the policyholder needs to foot the hospital bills and then claim for reimbursements from the insurer by providing the required documents.
In both of the above claims, there is a specified process and certain pointers that can enable a hassle-free claim experience.
Cashless Claims
If your policy provides for cashless claim facility, you need to keep the following pointers in mind at the time of hospitalization:
- Always look for the list of hospitals tied with the insurer called PPNs and ensure to avail treatment in any one of those hospitals for being eligible for cashless facility.
- Your hospitalization can either be planned or emergent. In case of planned hospitalization, inform the TPA by filling and submitting a Pre-Authorization Form well in advance so that the TPA begins the formalities to co-ordinate with the insurer. It is generally mandatory to submit the form at least 48 hours before a planned hospitalization. In case of an emergent hospitalization, the form needs to be submitted within 24 hours of hospitalization to begin proceedings.
- The Health Card that comes with the policy document should be produced at the hospital, which contains the identity of the insured.
- Insurers generally pay the claim in tranches where they pay a lump sum amount initially and later cover the remaining bill. So keep the TPA informed at all times and keep a copy of all hospital bills and doctor’s prescriptions as document proofs which will be required to ascertain a fair settlement.
Reimbursement
Though the cashless claim is the norm of modern times, there are policies which have reimbursement claim settlement. Even the cashless settlement may at times result in a reimbursement claim if:
- There is an anomaly in the Pre-authorization Form whereby the TPA rejects the cashless facility
- The policyholder is admitted in a non-network hospital
- The medical treatment costs less and the policyholder decides to get the bills reimbursed
- There is a coordination problem between the TPA and the insurer
At such times and for reimbursement policies, the following points should be remembered:
- The reimbursement claim form should be filled and submitted along with supporting documents in original.
- The supporting documents include the doctor’s prognosis prescription advising for hospitalization. This needs to be submitted to prove that the hospitalization was advised and not voluntary.
- All hospital bills, bills for tests conducted or surgeries performed, etc. need to be submitted in original.
- The Discharge Card issued by the hospital stating that the policyholder is declared fit to be discharged is also required.
- A follow-up prescription showing that the policyholder is fit after hospitalization is needed.
- A copy of all original bills and forms needs to be retained by the policyholder for future use.
- After receiving all the required documents, the insurers generally settle the bill within 15-21 working days.
The Final Word!
Whatever be the nature of your claim, keeping the relevant points in mind is very necessary to ensure a speedy settlement without the additional hassle involved at times when you are already under a lot of stress.
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Disclaimer: The list mentioned is according to the alphabetical order of the insurance companies. Policybazaar does not endorse, rate or recommend any particular insurer or insurance product offered by any insurer. For complete list of insurers in India refer to the Insurance Regulatory and Development Authority of India website www.irdai.gov.in
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*We will respond in the first instance within 30 minutes of the customers contacting us. 30-minute claim support service is for the purpose of giving reasonable assistance to the policyholder in pursuance of the claim. Settlement of claim (including cashless claim) is the responsibility of the insurer as per policy terms and conditions. The 30- minute claim support is subject to our operations not being impacted by a system failure or force majeure event or for reasons beyond our control. For further details, 24x7 Claims Support Helpline can be reached out at 1800-258-5881.
*Product information is authentic and solely based on the information received from the Insurer. Policybazaar is acting only as a facilitator and claims settlement shall be at the sole discretion of the Insurer. Policybazaar does not provide any medical or surgical advice or diagnosis and is not responsible for your interactions / treatment by a medical practitioner/hospital. Please consult a registered medical practitioner for any medical or surgical advice. The Information that you obtain or receive from Policybazaar, and its employees, or otherwise on the Website is for informational purposes only. As per the Insurance guidelines, you are allowed to cancel the policy with-in 30 days from the date of Issuance of policy.This option is available incase of policies with a term of one year or more.
*All the health insurance plans cover hospitalization expenses including COVID-19 treatment cover up to the specified limits. You can also buy specific COVID-19 health insurance policies such as Corona Kavach Policy and Corona Rakshak policy.
**All savings and online discounts are provided by insurers as per IRDAI approved insurance plans. #Tax Benefits are subject to changes in tax laws. GST Exemptions depend on fulfilment of qualification criteria and submission of relevant documents.
*₹1748/month is the starting price for a 1 crore health insurance for an 18-year-old male, with no pre-existing diseases. Discount on renewal premium is subject to the number of wellness points earned in the health insurance policy. For more details about the plans, please read the sale brochure carefully to get upto 100% discount on renewal premium.
*₹400/month is the starting price for ₹ 5 lakh Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases
*₹541/month is the starting price for ₹ 10 lakh Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases
*₹762/month is the starting price for ₹ 1 Crore Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases
*₹243/month(₹ 8/day) is the starting price for a 5 lakh health insurance for a 20-year-old male, non-smoker, living in Bengaluru with no pre-existing diseases
*₹2020/month is the starting price for ₹ 1 Cr Health insurance for a 50 year old male & 50 years old female, living in Bangalore with no pre-existing diseases rounded off to nearest 10.
*₹390/month (₹13 per day) is starting price for 1 cr. Health insurance for 25 years old male, with pre-existing diseases, residing from tier 1 city rounded off to the nearest 10.
*No medical tests are required unless requested by the insurer’s underwriter. In-case of pre-existing diseases relevant medical proof would be required as per the terms and condition of the policy opted.
*The values taken for effective cost calculation are indicative values and may change as per the selected plan.
*Coverage upto double the amount of Sum Insured is available on certain covers for a minimum plan of Rs. 5 Lakh on the first claim only to an individual of upto 45 years of age with no pre-existing diseases. The benefit is available with or without extra cost depending on the plan chosen.
*Coverage of pre-existing diseases is provided by insurer as per their underwriting policy.
*The scope of coverage may vary from plan to plan.
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