Insurance is a promise an insurer makes to the insured to assist them during their most difficult financial times, such as a medical emergency or accident. However, when such a situation arises, and your insurance claim is delayed or denied, it can be very upsetting, adding more stress to an already difficult time. Indeed, you (the insured) are also responsible for ensuring that a claim is honoured. How? There are some preventative measures that, if followed, can guarantee a quick and straightforward claim settlement.
The process of settling a health insurance claim will be simple and smooth when you are aware of the requirements and application process for settlements. To ensure this, let's first comprehend the claim settlement process.
Claim Settlement Process:
When a policyholder's attendant notifies the insurer of the occurrence of an "insured" event, the insurer immediately confirms the validity of that health insurance. To start the verification process, the network hospital will inform the insurer. Next, the treatment for which the claim is made will be double-checked by a field doctor assigned to the case. Finally, following verification, the insurance company's medical team will approve the insured's cashless claim per the policy's terms and conditions. It is how things generally go when you have health insurance.
So, in this process, what are the things that I should be aware of beforehand?
A. Types of Claim Settlement:
There are these two ways in which you can settle the claim-
1. Cashless Claim Settlement:
According to the policy document, you can only use the cashless claim option if you are admitted to a network hospital. The policy document mentions a list of network hospitals in your area of residence. This list is technically referred to as the Preferred Provider Network- PPN. Through Third-Party Administrators (TPA), who serves as a liaison between the hospital and the insurance provider, the insurance provider pays all costs directly. Therefore, you only need to give the TPA your cashless health card.
2. Reimbursement Claim Settlement:
You will need to pay the hospital bill and the cost of the medical care under this option, either immediately after the treatment or before discharge. After that, you must submit a claim for reimbursement directly to your insurer. According to the terms of the policy, the insurer will reimburse the cost of the medical care.
B. Steps for Filing a Health Insurance Claim:
Receiving financial assistance from your insured company is not difficult as long as you follow the procedure. To learn how to submit cashless and reimbursement claims, refer to the simple guidelines below:
1. Gather all of your medical records, invoices, and receipts for which you want to submit a claim, then arrange them chronologically. (See that all medical records contain the necessary information, such as the patient's name, the cost, the serial number, stamp, the physician's signature, etc.)
2. You are required to furnish a claim form. The insurance company's office will have it for you, or you can download and print it from their official website.
3. Then, please read the form's instructions carefully, then fill it out completely. Obtain the policyholder's and the resting consultant's signatures on the form.
4. Next, you will have to attach a few medical and policy documents to complete the form. The list of documents includes treatment documents, discharge summary of the patient, medical reports, recovery certificate of the patient from the attending doctor, TPA card (in case of a cashless claim) and NEFT details (in case of reimbursement).
5. The executive present at the TPA office should be given a copy of the claim documentation along with the file. Send one copy of your claim form to your health insurance provider, and let them know you have done so.
Even though the steps and procedures of claim settlement have been made more accessible, there are still specific tips to be kept in mind to ensure the claim settlement is hassle-free.
C. Tips for Speedy Health Insurance Claim Settlement:
Essential things to keep in mind for cashless claims or reimbursement procedures are:
1) The reimbursement claim form must be filled out and submitted along with the original copies of supporting documents.
2) The paperwork should contain a doctor's note recommending hospitalization. It must be provided to the insurer to prove that the doctor had suggested hospitalization.
3) The full set of original hospital bills must be deposited.
4) It is also necessary to have the discharge card that the hospital issued. The fact that the insured is fit for the discharge must be stated clearly.
5) The policyholder is required to save a copy of all invoices and forms for later use.
6) Additionally, a follow-up prescription is required. It must demonstrate the policyholder's fitness following hospitalization.
7) Either an urgent or a planned hospitalization is possible. Pre-authorization forms must be filled out and submitted well in advance to the TPA in case of planned hospitalization so that the TPA can start the procedures for coordinating with the insurer. The form must typically be submitted at least 48 hours before a scheduled hospitalization. In case of urgent hospitalization, the submission needs to be within 24 hours of hospitalization.
8) Apart from these, know your insurance rights. IRDAI states that the insurance company must pay penalty interest to the insured person if a claim settlement request is not approved or denied within 30 days of receiving the final required document.
Conclusion
Claim settlement has never been simple for either consumers or insurers. However, consumers can streamline the claim settlement process by keeping the crucial points mentioned in mind. The secret to quick reimbursements is to be ready and take all the necessary precautions to ensure complete document submission.
