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.

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.

How helpful was this page?