For any insurance policy, and especially for a health insurance policy, the moment of truth comes at the time of the insurance claim. The very goal of taking a health insurance policy is to ensure that during medical emergencies and also when you are seeking medical treatment, you don’t need to worry about the financial cost of treatment. Just as it is important to purchase an adequate health insurance policy it is equally imperative to understand the claims process so that at your time of need, you can fall back on your health insurance policy.
Now you have decided to invest in health insurance, there are several things which you should keep in mind. First of all, remember that the plan comes into play when you are hospitalized or when you have to shell out money for some medical reason. The health insurer will only process your claims if your medical condition is part of the coverage being offered so be sure to read the fine print. It is better to choose a slightly expensive plan with better coverage instead of opting for the cheapest option and then not receiving adequate coverage.
Health insurance policies admit two types of claims. These are:
Now, the most important thing about cashless claims is that it is hassle-free and seamless. Generally, most insurance companies have tie-ups with a network of hospitals and when you choose a partner hospital for treatment, you can avail of the cashless claim option.
Under a cashless claim, you would not have to pay any money – the insurance company will settle the claim directly with the hospital. This means that you can seek treatment at any of the network hospitals and the bills are directly settled by the insurance company, without you having to shell any money from your pocket.
In the case of a medical procedure that requires hospitalisation, you first need to check the list of network hospitals and then select one that meets your requirements.
Once you have selected the hospital, you need to inform the insurance company three to four days prior to the appointment and submit a pre-authorisation form. This form acts as a claim notification and helps you avail of cashless claim facilities. You have a few options here:
The completed form needs to be submitted at the insurance desk of the hospital. Once submitted, the TPA will process your form and share a sanction letter which will specify the maximum amount that has been sanctioned for your treatment.
In case of a medical emergency, inform the company and submit the form within 24 hours of hospitalisation. Following the submission, the company will assess the claim and move the process forward.
Under the reimbursement option, you will have to first pay for the bills and, once the claim is processed, the insurance provider will reimburse you for the money you have spent, as per the original hospital bills. Inevitably, this will not be as seamless as a cashless claim. However, you do not need to seek medical assistance only at a network hospital. You are free to choose any hospital.
Retain and submit all the required documents. Below is a list of the most important documents that you must have at the time of filing a reimbursement claim.
Upon assessing the documents, and pursuant to the coverage offered by the policy, the insurance company will then reimburse you for the expenses incurred during the hospitalisation.
Medical emergencies are a major cause of concern and you may forget the claims process given the stress of the moment. These are some of the things which you should remember in such situations –
Required documents – In addition to the pre-authorisation form and original medical documents, you should also submit documents like a valid ID proof, bills of equipment and tools used during the operation, canceled cheque, copy of the policy plan, and any other documents mandated by the service provider.
Remember that health insurance claims are only valid in line with the sum insured limit chosen by you. In case your claim surpasses this limit, you would be forced to pay the excess yourself. It is best to check the sum insured and choose a policy with adequate coverage.
Beware of the exemptions – Every health insurance policy may have a few exemptions which you need to be aware of. You will not receive insurance for the exemptions so choose your coverage accordingly.
Remember the timeline of the claims process as non-compliance could lead to delays in the processing and also hamper you from availing the cashless claims facility.
If you are choosing the cashless claims option, keep a list of the partner hospitals handy in case of an emergency.
Ensure that you renew your health insurance policy before it gets lapsed as you will not be able to claim insurance if your policy lapses.
Wherever you need our assistance, please call us and one of our team will guide you through the process
