process health insurance

Steps to get your insurance settled

When we buy a health policy, claim settlement is one area we panic the most. With our assumptions, we think the process is complicated because of the lack of proper awareness; it can indeed be hassle-free.
Today, we shall help you with the process to claim settlement on your health policy.
Claim settlements are done in two ways:

  1. Cashless claims
  2. Reimbursements

Steps for Cashless Claims

If it is a planned hospitalization (a situation where you are aware that after a few days, you need to avail medical treatment), you can go for a cashless settlement. Below are the steps you need to follow:

Step 1. Check:

When you wish to opt for cashless hospitalization, you need to check the two critical things:

  • Whether the ailment is covered as per the Terms and Conditions of your health insurance policy?
  • Whether the hospital is in the network tie-up of the insurance company?

Step 2. Intimate:

Whenever you wish to claim on your insurance policy, it’s utmost important to intimate the same to the insurance company i.e., either cashless or reimbursement. At the hospital, during admission, you will be asked to fill a Pre-Authorization Form and submit the same at the TPA (Third Party Administration) counter. They will further forward the form to the insurance company for the cashless approval.

Step 3. Documents Submission:

At the TPA counter, you will be required to submit the documents like the Cashless Health Card provided by insurance company along with certain KYC – Know your Customer documents for identity. They might take a copy of the same and return the original documents.

Step 4. Record Keeping:

Once the cashless approval for the claim is received from you, your original documents about the hospitalization will be retained by the insurance company. Hence, it’s advisable to ask for a copy of the same for your records.

Step 5. Pre-Post Hospitalization:

Check about the pre and post hospitalization cover in your health policy. You need to retain the bills and all associated prescriptions/medical reports to claim the same. This claim is always made on a reimbursement basis. Kindly refer to the Policy Wordings for the timeframes related to the same.

Reimbursement Claims – Steps to follow

Some plans do not provide a cashless claim facility, and you have to reimburse the expenses. Reimbursement happens when you seek treatment in a non-network hospital or if you fail to opt for cashless settlement. Whatever be the scenario, the following steps are to be followed in case of a reimbursement claim –

Step 1:

Inform the company and submit the duly filled reimbursement claim form available with the insurance company within 30 days from the date of discharge from the hospital.

Step 2:

Attach all the original copies of the medical reports, medical bills, and hospital bills duly stamped and signed with the claim form. The hospital bill should mention the Registration No of the hospital. The reports should indicate the name of the patient and date. It should also be attached along with the prognosis prescription of your doctor who advised on hospitalization. It shows that your hospitalization or medical prescriptions were not voluntary but as per your doctor’s advice.

Step 3:

After being discharged from the hospital, the hospital will issue a Discharge Summary/Card, which claims that you are fit to be discharged. This Card is to be submitted to the insurer.

Step 4:

Your doctor’s follow-up prescription, which shows your fitness after hospitalization, is also needed to be submitted in original. For post-hospitalization expenses, you can submit the bills within 60 or 90 or 120 days from discharge, depending on the terms of your insurance policy.

Step 5:

You should retain copies of all submitted documents for future reference. Your claim will be settled within 2-3 weeks after the claim is registered with the insurance company.

For Warren Buffet once said…

“The best investment you can make is an investment in yourself. The more you learn, the more you’ll earn.”

Thus, understanding the claim process is vital for a seamless claim settlement, be it cashless or reimbursement.

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