The main purpose of getting health insurance is to get a financial back up in case there is a medical emergency. When that happens, you raise a claim on your health insurance policy. If the claim is honoured, the insurer pays the amount and you receive the coverage you paid for. However, claims do get rejected for various reasons. One of the main reasons is following an incorrect procedure when filing the claim. To ensure your health insurance claim is not rejected, you must follow the correct steps. Read on to know more.
5 Steps for a Cashless Claim Settlement
If your policy has provisions for cashless health insurance, you need to follow the steps mentioned below:
- Verify
Before you begin the treatment, verify a few facts. First and foremost, read your policy wordings and see whether or not the particular ailment is covered under the health insurance cover. Then, check to see if your chosen hospital is listed as one of the network hospitals. Remember, your cashless claim will only be honoured if both of these factors are checked and you choose to get admitted in a network hospital. - Inform
Next, you need to inform the insurance provider about the upcoming hospital stay. If it is a planned hospitalisation, you need to inform the insurer at least 48 hours in advance. If it is a hospitalisation due to an emergency, the insurance company needs to be informed within 24 hours of getting admitted. You also need to submit the pre-authorisation form to the hospital or TPA.
So, basically for a cashless claim, you need to get a pre-authorisation from the insurance company or its TPA (third-party administrator) desk which states that your claim would be processed by your insurer. It also provides the initial approval so that the treatment can start and then the rest of the amount would be settled on final approval at the time of discharge. - Documentation
The documents needed for a cashless claim are, thankfully, quite minimal. Since the insurer and the hospital connect directly, your role is not too much. You just need to submit the health insurance policy card and certain KYC documents to prove your identity.
The list of most important documents for your cashless claim that you need to provide at the time of hospitalisation would be:- Health Insurance Card and Policy Details
- The insured’s KYC documents, i.e. Identity and Address Proof
- The doctor’s advice on hospitalisation
For emergency hospitalisation, the resident doctor at the emergency ward can provide the same - Pre-authorisation from the insurance company
- The rest of the documents would be provided by the hospital on your behalf and the photocopy of the same would be provided to you at the time of discharge.
- Keep Records
Once the bill is settled by the health insurance company, you will get a photocopy of all your treatment details at the time of discharge.
However, you need to take a certified true copy of all the original documents submitted by your hospital to the insurer, in case you need to file another claim with another insurance company. - Pre and Post Hospitalisation Expenses Need to be Reimbursed
Though the cost of the hospital stay is settled directly by the TPA desk of the hospital in a cashless manner, you may need to get certain expenses reimbursed. These mainly include the pre and post hospitalisation covers, ambulance cost, medicines, diagnostic tests, doctor consultation, etc. You need to get these expenses reimbursed by submitting original bills, doctors’ certificates, etc.
These are some very simple steps that ensure your cashless insurance policy claim process becomes smooth and hassle-free.
5 steps for a Reimbursement Claim Settlement
A cashless claim is straightforward because the insurer directly deals with the hospital and your role is minimised. However, when you opt for the reimbursement claim, the steps usually become a bit more lengthy. Thankfully, the below- mentioned steps are quite simple:
- Intimate the Insurer
Start off by informing your insurer about the upcoming hospital stay. If you need to get hospitalised in an emergency situation, you need to inform the insurance company at the earliest.
There is a specific time limit for each and every insurer for intimation and also to file your reimbursement claim, which is no later than 90 days from the date of hospitalisation. If you fail to meet this deadline, the reimbursement claim might not be approved. - Documentation
Remember to keep and store each and every document related to your hospital stay. These include the original doctors’ prescriptions, the bills and memos, the pharmacy receipts, the diagnostic test results, etc. You will have to submit everything in original to ensure your health insurance claim insurance settled quickly and smoothly.
The list of documents that need to be submitted for a reimbursement claim is:- Health Insurance Card and Policy Details
- The insured’s KYC documents, i.e. Identity and Address Proof
- The policyholder’s bank account details with the cancelled cheque for reimbursement
- The doctor’s advice on hospitalisation
For emergency hospitalisation, the resident doctor at the emergency ward can provide the same - Original bills and receipts of all expenses like diagnostic tests, medicines, etc.
- Original reports of all tests done to confirm the diagnosis
- The original discharge summary at the time of discharge which confirms the treatment done and the course of action thereafter
- At the time of discharge, the hospital will issue a discharge summary stating details related to your hospital stay. It will also mention that you are now well enough to go back home. The insurance provider will need to see your discharge summary so make sure you collect it from the hospital and submit it when making the reimbursement claim on your medical insurance policy.
- Get the Fitness Certificate
The doctor treating you will issue a fitness certificate stating that the treatment was a success and you are now fit. This is another important document that you need to collect and submit to make sure you get the claim smoothly. - Keep Records
Do not forget to keep a record of every submission you make. A good idea would be to make a separate file and put in photocopies of the exact documents you submitted to the insurer, into the file. Keep the file with yourself so that in case there is a future dispute, you can go back and verify what went wrong. - Pre and Post Hospitalisation Expenses can be Reimbursed Together with the Claim
The pre and post hospitalisation like ambulance cost, medicines, diagnostic tests, doctor consultation, etc. can be reimbursed along with the actual claim.
As you can see, the steps to make a successful reimbursement claim on your health insurance policy are quite easy to follow.
In a Nutshell
Whether you have a cashless health insurance plan or a reimbursement cover, getting the claim is your right. You pay the premiums regularly and when there is a requirement, the insurance provider must pay the claim to you. To make the process smoother and faster, follow the steps mentioned above. If you file the claim in a methodical and correct manner, the chances of the claim getting rejected become much lower.
