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How To File A Health Insurance Claim ?

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In certain circumstances health insurance claims can be a frustrating process and more so if there is no help from the healthcare provider. Often people are left to fend for themselves while filing a health insurance claim for a medical procedure which occurs after hospitalization. In such a situation cashless facility will not be provided by the hospital or nursing home. The expenses incurred on hospitalization can be claimed only after the patient gets discharged from the hospital or on completion of treatment. If one has to file a health insurance claim, they must keep all receipts and arrange them in chronological order. Get the claim form from the health insurance company, prepare copies of the original for the purpose of claim submission, review and dispatch documents and understand the fine print in the policy document. You should keep not only all receipts, bills and medical reports as part of the hospitalization but also the ones obtained during 30 days prior to and 60 days after hospitalization. The medical services availed during this period as part of the same treatment, are generally applicable to be reimbursed. While filing the health insurance claim, all the receipts, bills, discharge summaries, investigation reports, consultation sheets etc. need to be submitted in original and copies. Retain a copy incase the documents are misplaced or lost.

Types of Health Insurance Claims

Usually, one can file a claim via any of the following ways:

• Cashless Claims:

For this, you would requirea Cashless Health Card. A cashless mediclaim can only be filed in a network hospital. A network hospital is the one with which the health insurance company has a tie-up. Your insurer will directly settle the bills with the hospital. In case of a cashless claim you just have to pay a small amount against deductibles.

• Reimbursement Claims:

In this case, the treatment need not be a network hospital and can be at a facility of your choice. In this type of claim, you first have to pay the entire cost related to the treatment, gather necessary invoices and other documents and then file for a reimbursement claim. Once your claim is approved, your health insurance company will pay the claim amount after subtracting the deductible.

Steps for Filing a Cashless Health Insurance Claims

1. Step 1 Coverage

Be aware about the exclusions and inclusions of a policy. This will be helpful at the time of availing treatment in a hospital and in avoiding claim rejection. Keep in mind the names of the network hospital. To submit a claim for cashless health insurance policy, you need to avail the treatment in a network hospital in case of a medical emergency. Thus, buy from a health insurance company that has a strong number of hospitals.

2. Step 2 Communicate with your insurer

For a cashless claim, you do not have to keep a record of the bills however you need to get in touch with the Third Party Administration (TPA) or your insurance company. He/she will help you to fill a Pre-Authorization Form. This will help in claim approval for your cashless mediclaim policy. The Cashless Health Card and identification details might be asked from you, so keep them handy.

Step-by-Step Procedure for Filing a Reimbursement Claim

Reimbursement claim is like a back-up for cashless claims. If you do not avail treatment in a network hospital you will have to settle the bill amount with the hospital and then file a claim.

1. Step 1 Inform

You might file for a reimbursement claim later, but you need to inform your health insurance company when you begin availing treatment at the hospital of your choice.

2. Step 2 Apply

You need to get the claim form, either from your insurance agent or download it from the website of your insurer if this facility is available. Fill the form and attach the required documents, for example: bills, discharge summary, etc.

3. Step 3 Post-Hospitalization

The insurance company may also ask for a fitness certificate after hospitalization. In case of any post-hospitalization treatment, submit those bills as well. Your claim shall be processed within a few weeks and you will receive the maximum claim amount. As mentioned earlier, make sure to read the health insurance policy at the time of purchase. Try to understand all the important terms and conditions of the policy documents. This will help you in the claim process.

Conclusion

In order to file your health insurance claim, the next step is to get the claim form from the insurance company. Alternatively, the claim form can be downloaded from the official website of the health insurance company. After completing the compilation of the claim to be reimbursed, re-check your documents. Verify the documents and see that no document issued during the treatment process is missing. This is necessary to avoid a claim shortfall. Check whether all the documents are relevant to the treatment for which the health insurance claim is to be submitted. Ask the health insurance company to which Third Party Administrator the claim documents have to be submitted.

Usually all health insurance claims have to be filed within 7 days of completion of treatment or discharge from the hospital. Remember that health insurance companies will not honor claims in case the documents are not as per their terms and conditions. Understand that the entire medical expenses incurred during hospitalization may not be reimbursed to the health insurance policyholder. Make a note of the deductions or the medical expenses that are not included in the cover. Understand and get a clear picture of the entire process. This is of utmost importance as such expenses incurred as part of the medical treatment will not be reimbursed to the claimant.

Disclaimer: The above information is for illustrative purpose only. For more details, please refer to policy wordings and prospectus before concluding the sales.

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