Everything You Need To Know About Health Insurance Claims – Forbes

Health insurance is useful when it comes to covering the medical expenditure arising out of an illness or hospitalisation. Comprehensive health insurance plans cover expenses such as cost of medicines, cost of hospitalisation and surgeries, cost of doctor consultation, among other aspects. 

Why Choose A Health Insurance Plan

Some of the major reasons for subscribing to a health insurance policy include:

Safeguard against lifestyle illnesses: Nowadays, more and more people are falling prey to lifestyle diseases such as diabetes, obesity, heart disease, pulmonary issues, etc. While these diseases were previously common among people in their later years, due to sedentary lifestyle and increased stress, these diseases are taking a toll on the younger populace. 

If you are not prepared to face the fallout from a potential illness or condition, you may stand to lose a heavy amount on tests and medication as many of these diseases are chronic. A comprehensive health insurance protects you from the bills that crop up during regular tests and also offer you help in taking care of medication expenses. 

Protection for the whole family: Health insurers offer comprehensive plans which cover the medical requirements of the entire family. With hyper-personalisation now an option, it is possible to choose health covers which protect all the different requirements of your entire family without burning a hole in your pocket. 

Having a comprehensive family health cover will hold you in safe stead in case of any untoward incidents while also protecting your family and enabling you to provide them with optimal healthcare facilities.

Buffer against medical inflation: Inflation is rising every day and this is visible across all categories of goods and services. With constant innovation and new age medicines entering the market, the cost of treatment is rising steadily. 

Everything from consultation charges to cost of medicines, hospitalization, and ambulances, are rising consistently and subscribing to a comprehensive health insurance plan can help you stay ahead of the inflation curve. You can receive quality treatment, years from now, without worrying about the rise in inflation. 

Safeguarding your savings: If you and your family do not have a comprehensive medical cover and fall prey to illness or meet with an accident, you may be forced to dip into your hard-earned wealth and savings to access effective treatment and medical facilities. Insurance ensures that your savings do not go down the drain in case of a health emergency. 

How A Health Insurance Claims Process Works

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.

Once you decide 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:

Cashless claimsReimbursements

Cashless claims

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. 

Steps for Availing Cashless Claims

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 cashless claim facilities. You have a few options here:

1. Generally, most of the network hospitals will have a dedicated insurance desk. You can collect the form from this desk.
2. You can directly connect with the insurance company via email or a phone call to the toll free number and collect the form from their claims desk.
3. You can download and print the form from the TPA’s (Third Party Administrator’s) website. A TPA is an outside entity that is appointed by the insurance company to facilitate the claim related procedures on its behalf. A TPA has to be licensed by the Insurance Regulatory and Development Authority of India (IRDAI). 

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.  

Reimbursement claims

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. 

Steps for Availing Reimbursement Claims

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. 

1. The claim form, duly filled and signed by the claimant. This form can be downloaded online or obtained from the insurance company’s office. 
2. Hospital discharge certificate, summary report, your case file, and any other document related to your treatment. You must ensure that all these documents are signed by your case doctor at the hospital. 
3. All your original bills, cash memos for medicines, and receipts. 
4. In case the medical treatment that you availed was as a result of an accident, then you must also submit a copy of the First Information Report (FIR) that you filed with the police. In case an FIR is not available, then you must provide a Medico-Legal Certificate.

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.  

Things to Keep in Mind When Raising A Health Insurance Claim

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, cancelled cheque, copy of the policy plan, 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.  

Bottom Line 

While there are several things to be kept in mind while choosing a health insurance policy, it is always better to be safe than sorry. And this has proved especially true in the post-pandemic world, where we are battling unprecedented incidents on a regular basis. 

Investing in a health insurance policy is important to your long-term financial and overall wellbeing as the policy helps you save your wealth and also ensures that you have enough funds to avail the best facilities possible. Make sure that you choose the best health policy in line with the requirements of yourself and your family members.