File A Claim

How to file a claim & what is the process?

So there are two types of claim processes. i.e. cashless and reimbursement.

1. Cashless

• As the name implies cashless means that no cash is required for the claim (Although the policyholder must pay File charges, etc. and the claim is paid up to SI).
• An insurance company has affiliations with hospitals. A policyholder can go to the nearest network hospital for cashless treatment. The list of network hospitals is updated on the insurance company's website.
• Hospitals have agreements with insurance companies. A policyholder can seek cashless care at the nearest network hospital; the list of network hospitals is updated on the insurance company's website. The hospital is paid directly by the insurance company for treatment costs and medical expenses. Always choose cashless care at your preferred network hospital, and always consult the network hospital list for the best and quickest treatment by your doctor.
• Documents related to the cashless claim process: Health Insurance policy / Health Cards, I.D Proof related Document, Date of Birth proof Document, Doctor's prescription.
• Pre-authorization: Another method for starting the patient's treatment through the claim. You already know what treatment or surgery will be performed? In this case, your first step is to notify the insurance company about the treatment and the doctor at the policy company's network hospital. After reviewing the medical documents, the claim is generated. The doctor will provide the policy company with a detailed prescription for the treatment as well as the estimated cost of the treatment, and the policy company will approve the pre-authorization claim after cross-checking the related documents.

2. Reimbursement

• Reimbursement means, the policyholder is paying for the treatment by himself/herself and then files a claim with the help of bills of the treatment which was paid during the treatment.
• Documents for the Reimbursement claim process: When filing a claim, you must provide certain supporting documentation. There are two methods for filing a claim: Offline and Online.
• Nowadays, most companies work digitally, and to apply online, simply visit the company's website or application and follow their guidelines, while to apply offline, you have to submit documents physically, and simply organize a file with the necessary documents. Like: Original Documents (diagnosis reports, discharge Summary, bills/receipts, medical reports/tests), KYC document, Identity card, Cancel cheque.

Pre & Post Hospitalization claim

• There are two important terms, you should understand before getting your insurance, pre-hospitalization expenses and post-hospitalization expenses. If you have been admitted to the hospital for a medical illness following which, you file a claim which was approved by the insurer then all the diagnostics and medical expenses done by the patient before being hospitalized are called pre-hospitalization expenses.
• Further, when you get finally discharged from the hospital the cost of medicine, test, and doctor fees for follow-up treatments are termed post hospitalization expenses.
• When you file a claim for medical expenses most health insurers will cover the pre-hospitalization and post hospitalization expenses in the claim, however, these expenses are covered for a certain number of days only, which is mentioned in the policy document.

IRDAI Guidelines for the better Cashless Claims

• IRDAI has always been working for policyholders and companies to help them in giving better and easy services. IRDAI has been a better step-ahead for the policyholders in their new guidelines on 20th July 2022. It was termed as cashless hospitalization through a preferred partner network.
• Scope of coverage will increase: The scope of coverage of policies has been increased across the length and breadth of the country. It has been stated that the list of cashless network hospitals will increase and following the quality control of the same will be better for the claim process and treatment. Here insurance company must set up some quality checklist criteria so it will also help in tying up with more hospitals that provide a better quality experience and services to the policyholder.
• Some benchmark setup by IRDAI that every network hospital should follow like: Minimum Manpower, Minimum Infrastructure Requirement. Hence it all will provide better and hassle-free cashless claims and ease for the policyholder!

Instructions for an easy and quick pre-authorization medical claim:

• In India, the cashless claim process is used to pay for various services at hospitals, and once the patient arrives at the hospital and requests assistance, the hospital is required by policy to begin treatment as soon as possible. (Although, the Policy Company will approve or reject the claim and provide a pre-authorization letter (if approved) for the patient)
• But first, the Customer must submit his/her/patient's details for approval. As you are aware, there are two types of claim processes: cashless and reimbursement claims. We'll go over every step of the claim process here.

STEP 1 : Locate the closest network hospital.

• The process begins when the customer arrives at the network hospital for cashless treatment of the patient to provide better care and treatment (although the hospital could be a network hospital or another hospital that is not listed in the policy company).
• The customer must complete a claim form and provide all necessary documents before proceeding with the procedure. The following documents are required for the claim: Health Insurance policy / Health Cards, Identification Proof Document (Aadhar card/Voter ID card), Proof of Date of Birth Document (Aadhar card), Doctor's prescription.

STEP 2 : Verification

• Once you have submitted the necessary documents for the claim, you must wait for approval from the insurance company.
• The hospital will check the customer's information and send the duly completed pre-authorization form to the insurance company. Once verified with policy benefits, the insurance company sends an authorization letter back to the network hospital. (Depending on the terms and conditions of the individual company, the pre-authorized request may take up to 2 to 4 hours.)

STEP 3 : Approval Received

Once the pre-authorization is authorized and received by the network hospital, the hospital begins treating the patient without any expense until discharge, it may alter depending on the terms and conditions of the insurance or the different companies. The policyholder is mandated to pay File charges, and the claim is paid up to SI. Treatment charges and medical expenditures are paid directly by the insurance company to the hospital (try to pick cashless treatment in your closest or preferred hospital for a hassle-free claim).