Owing to the rising Medicare costs in recent years, the gap between care costs and its affordability has also proportionately increased. An adequate Health Insurance is hence becoming crucial for bridging this gap. Due to a significant rise in lifestyle diseases, health insurance is now seeing a gradual uptake among customers.
However many still remain unaware of availing insurance benefits during a claims scenario. Be free from last moment hustle and resolve them by being aware of the procedure of filing the claims against health insurance.
During the time of filing claims of Health Insurance, one can choose from two facilities provided and those are reimbursement mode and cashless mode.
Cashless Claims
When treatment takes place within a network hospitals of insurer, cashless mode facility can be used. With this facility, the insured is not required to shell out any sum for the treatment except for the non-medical items. This is a direct mode of claims settlement where the insurance company settles the payment directly with the hospital depending on the insurance policy terms and conditions and the sum insured that the customer has opted for. The advantage of cashless claim can be availed for unplanned as well as planned types of medical treatments.
In order to avail the cashless claims benefit, a customer needs to follow the below mentioned procedure:-
- In case of planned hospitalization, it is important to take a pre-authorization from the insurer, including sharing treatment and its corresponding expense details with the insurance company through the hospital. Generally, this approval should be taken 4 – 7 days prior to the treatment, however, it may vary from insurer to insurer.
- Once you connect with your insurance company, they will inform you about the documents that may be required. Post sharing these documents and medical details with the insurer, it evaluates the treatment details as per policy terms and conditions and informs the concerned hospital and insured.
- The customer needs to produce the following documents at the network hospital in addition to the documents that are specified by the insurer:-
- Pre-Authorization Letter
- ID card issued by the insurance company
- Health Insurance Policy
- Aadhaar Card, Pan card / Form 60
- The original bills after the treatment are over and the patient has availed the facility of cashless mode, the treatment evidence, and original bills are left at the hospital. The hospital shares these bills with your insurance company and accordingly payment is processed by the insurer to the hospital.
- In case of any unplanned or emergency medical treatment, the policyholder can simply contact the insurer through its customer care centre or chatbot facilities to know about the empanelled hospitals. While being at the hospital, the customer can avail the facility of cashless hospitalization by insurance card offered by the insurer with the copy of the policy.
- Once the customer makes this request, hospital connects with the insurance company by filing the pre-auth request form and consequently the insurer issues an authorization letter to the hospital and also shares details pertaining to the policy coverage of the customer.
- Once the treatment is over, the insurer will then settle the payment of admissible claims.
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Reimbursement Health Insurance Claims
Reimbursement mode is another procedure that can be opted to settle the claim of health insurance. This situation mostly arises when a patient chooses the hospital as per his choice and convenience and the hospital is not empanelled with the insurer. In such scenarios, a policyholder has to make the payment for all the medical bills that are related to the said treatment and later on files the claim for reimbursement.
The reimbursement procedure is usually as follows:
- The insurance company evaluates the documents and maps it against the policy coverage.
- The customer is required to provide necessary documents along with the original medical bills to the insurer at the time of claim filing. These documents typically include a claim form, bank details, ID Cards, hospital discharge summary, investigation and diagnosis reports and bills, original hospital and pharmacy bills along with paid receipts and prescriptions. Additionally, in case of an accidental hospitalization copy of FIR also needs to be shared with the insurer.
- Post the evaluation the insurance company makes the payment to the beneficiary as per policy terms.
- On Nonreceipt of certain mandatory documents, the insurer can ask for these additional documents to take a decision on the claim.
- In case of claim repudiation, the insurer provides the grounds on which the claim is not payable.
A health insurance is a stitch in time. However, to ensure that it is a backstitch, it is highly advised to be aware of what your policy offers at the time of purchase itself. A detailed understanding of what’s covered and what does not help you to avoid any last minute ordeal.
