Claim Settlement Process in Health Insurance

The role of health insurance is unfathomable these days as it covers your family’s medical expenses at the time of hospital emergency or injuries. Especially after the COVID-19 pandemic, health insurance has entered the top-most priority list of people. To cope up with this rising demand, insurance companies are embracing customers with diverse health insurance plans. But people who have taken health insurance plans often find that the insurance companies reject their claims. To avoid the pain of rejection, everyone should have adequate knowledge about the health insurance claim settlement process.

Types of Health Insurance Claims

There are two types of health insurance claims.

  1. Cashless
  2. Reimbursement

Let’s dig deeper and understand these two health insurance claims.

1. Cashless Claim Settlement

Policyholders are eligible for cashless settlement when they opt for treatment in a networked hospital. A networked hospital is one that is partnered with an insurance company. Since treatments are carried out in a networked hospital, the insurer directly settles the hospital bills with the hospital. Therefore, you don’t need to invest a single penny from your pocket for your treatment.

Below are the steps if you want to enjoy a cashless claim settlement:-

  • For a pre-planned treatment, you must intimate your insurance company before your admission. You should inform the company at least 3 to 4 days prior to being hospitalized. You need to fill up and submit a pre-authorization form to the insurance company. This form acts as a claim notification.
  • In case of a health emergency (when the insured policyholder needs to be hospitalized under an emergency), you need to inform and submit the pre-authorization form within 24 hours of hospitalization.
  • After submitting the pre-authorization form, the insurance company will evaluate the claim based on the form and then grant cashless claim settlements.
  • The insured policyholder can get the best treatment from the hospital without paying anything.
  • All medical bills, tests reports, and other medical documents must be submitted to the insurer.
  • If other expenses are also covered, then you must submit the documented proofs (original) of such expenses to the insurer.

 

2. Reimbursement Claims

In case of a reimbursement claim, the policyholder first pays the medical bills himself and then, all these expenses will get reimbursed from the insurance company. A reimbursement claim is applicable if the insured policyholder avails of treatments at a non-networked hospital.

Below are the steps for health insurance claim reimbursement:-

  • The insured policyholder should get admitted to a hospital that is not partnered with the insurance company and seek medical treatments for his/her illnesses.
  • The insured policyholder should collect all the original medical reports and bills. The insured first needs to pay all these bills from his/her pocket.
  • After getting discharged from the hospital, the insured policyholder should collect the discharge certificate or discharge summary where everything is mentioned by the hospital authority including, the line of treatment, treatment period, and so on.
  • Then, the policyholder needs to submit the discharge certificate or summary to the insurer along with a duly filled in claim form, medical reports, original bills, and other relevant documents.
  • Based on your submitted documents, the claim form and expenses, the insurance company analyses your claim. After satisfaction, the company pays back the medical expenses to policyholders.

 

The documents required for Health insurance claim submission

  • Health insurance ID card
  • All doctors’ consultation papers
  • Claim form (properly filled up)
  • All investigation and diagnosis reports (X-RAYS, MRI, ECG, CT scan, blood reports, etc.)
  • In case of an accident, submit the FIR/Medico-Legal Certificate
  • Receipts of the pharmacy along with prescriptions
  • Discharge summary
  • All other relevant documents

 

Points to remember for Hassle-free claim settlement 

There are certain points that an insured policyholder should remember for a hassle-free claim settlement process.

  • The sum insured limit

Health insurance claims are allowable only up to the sum insured limit of the health insurance policy. If the claim surpasses the sum insured amount, the insured policyholder needs to pay the excess amount. So, every policyholder should check and be aware of the sum insured limit before applying for a health insurance claim.

  • Exclusions

Health insurance plans do not cover certain scenarios or health conditions. These are known as exclusions. If the policyholder files a claim for an excluded expense, the company will reject the claim. So, a policyholder should go through the exclusions of the health plan before making a claim. In case of a rejection, the policyholder has the right to know the reason for denial.

  • Timeline

In case of a cashless claim, there is a timeline for submission of the pre-authorization form. For planned treatment, the pre-authorization form should be submitted 3-4 days before admission. On the other hand, the form should be submitted within 24 hours in case of an emergency. A policyholder should obey these timelines to enjoy cashless claim settlements. If the timelines are breached, the claim might get delayed or rejected.

  • List of networked hospitals

A policyholder is eligible for a cashless claim service if he/she gets admitted to network hospitals of the insurance company. You can get the list of the network hospitals from the insurance company’s website.

  • Validity of the insurance policy

Health insurance claims are only applicable if your health insurance policy is valid and not lapsed. Your claim will be denied if the policy has lapsed. So, renew your policy on time and enjoy easy claim settlements.

 

When does a claim get rejected?

A health insurance claim gets rejected in 3 ways.

  • If the policyholder files a fraudulent claim
  • If the policyholder applies a claim during the waiting period
  • A policyholder makes a claim for an ailment (cosmetic surgery, obesity treatment, etc.) that is not included in the policy

 

How do you check the status of your health insurance claim?

By visiting the insurance company’s official website, you can check the status after entering all relevant details.

 

Health insurance policies play a pivotal role in protecting yourself and your loved ones in case of a medical emergency. An apposite knowledge of health insurance claims will make your claim settlement process facile and help you avoid medical insurance claim rejection.  

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