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Health Insurance Claim

Health insurance is designed to help in reducing the costs of medical care and provide a safety net for health issues. In 2021, health insurance schemes in India covered around 514 million individuals, representing only 37% of the country’s population. There are different situations where you would need to file a claim with your insurance policy, such as planned or unplanned visits to the hospital. You can submit a claim in two ways: through a cashless process or reimbursement.

Understanding the specific procedures for these claims to have a hassle-free experience and comply with the insurance company’s guidelines is essential. When you are hospitalised or face a medical emergency that requires expenses, your health insurance policy becomes active. If the policy covers the costs, it is considered a health insurance claim, and the insurance company pays for the medical expenses resulting from the medical issue.

Types Of Health Insurance Claims:

Due to the increasing number of health-related problems, treatment costs have significantly increased. Consequently, there is a growing demand for health insurance plans. As a result, various types of health insurance policies are available in the market to help improve the financial burden. These insurance plans enable individuals to access quality healthcare and provide peace of mind by reducing expenditure. However, choosing the appropriate insurance plan can be challenging due to the many options available today.

  1. Hospitalisation Claim:
    A health insurance policy with a hospitalisation claim provides coverage when they become sick and require hospitalisation. The objective of a hospitalisation claim will cover various expenses related to sudden illnesses or accidents, including hospitalisation, diagnostic tests, and surgical costs. These expenses are collectively referred to as ‘hospitalisation expenses.’

    However, there are also costs associated with being ill before being admitted to the hospital, categorised as pre- and post-hospitalisation expenses. Most comprehensive individual and family health insurance plans, typically include coverage for these expenses.

  2. Hospitalisation Death Claim:
    In the hospitalisation death claim, the other family members will still have coverage if the primary insured person passes away. It is because a hospitalisation death claim provides coverage for all family members under one policy. However, it is essential to inform the insurance company about the death of the primary insured person so that the policy can be updated accordingly.
  3. Accidental Claim:
    All health insurance plans include coverage for accidental injuries, which covers the medical costs associated with treating injuries sustained in a road accident. This claim typically includes charges for emergency hospitalisation and ambulance services. Some claims also cover expenses for post-hospitalisation treatments like consultations and physiotherapy that result from accidental injuries.

    Specific accidental claims may also provide a daily cash allowance for hospitalisation. It is important to note that health insurance plans offer immediate coverage for emergency unexpected hospitalisation without any waiting period. However, personal accident coverage is not included in regular health insurance plans and must be obtained separately through a personal accident insurance plan.

  4. Critical Illness claim:
    The critical illness claim provides coverage for life-threatening diseases by offering a predetermined lump sum amount. This claim includes specific health conditions diagnosed with any of the predetermined medical conditions. Hospitalisation is not necessary to file a claim under this category. Only the disease diagnosis is required to receive the benefits of the claim.

    The amount to be paid is predetermined and does not depend on pre- or post-hospitalisation expenses. The following is a list of all the critical diseases covered under the Critical Illness claim:
    1. Kidney failure
    2. Primary pulmonary arterial hypertension
    3. Stroke
    4. Paralysis
    5. Major organ transplant
    6. Cancer
    7. Aorta graft surgery
    8. First heart attack
    9. Multiple sclerosis
    10. Coronary artery bypass surgery.

  5. Claim For Daycare Procedures:
    Many health insurance policies now cover daycare treatment procedures that take less than 24 hours. However, not all insurance companies protect all daycare procedures, so checking what types of daycare treatments are covered before purchasing a policy is essential. Daycare treatment procedures include medical operations, treatments, and surgeries that require less than 24 hours of hospitalisation.

    Examples of daycare procedures include radiotherapy, cancer chemotherapy, angiography, and appendectomy. While most health insurance policies generally have daycare coverage, the specific list of covered procedures may vary among insurers. Here are some commonly covered daycare procedures:
    1. Septoplasty- Nose
    2. Cataract- Eyes
    3. Adenoidectomy- Throat
    4. Angiography, Chemotherapy, Radiotherapy- Others
    5. Appendectomy- Gastro
    6. Piles/fistula- Rectal.

  6. Pre And Post-Hospitalisation Claim:
    Most health insurance hospitalisation claims focus on covering the costs of being hospitalised. However, by having a comprehensive policy, you can receive additional advantages that extend beyond just hospital expenses. It includes coverage for medical costs before and after hospitalisation, known as pre- and post-hospitalisation expenses. Here is the description:

    1,Pre-Hospitalisation Claims: Medical expenses occur before a patient is admitted to the hospital. It involves tests and procedures conducted to diagnose a patient’s condition before they receive treatment in the hospital.
    Examples include diagnostic tests, X-rays, medication, CT scans, investigative procedures, MRIs, angiograms, and more. These expenses incurred within 30 days before hospitalisation are covered, but this coverage may vary depending on the insurance company.

    2. Post-Hospitalisation Claims: In most cases, the treatment and recovery process does not end immediately after leaving the hospital. Post-hospitalisation expenses refer to the costs incurred after a patient is discharged from the hospital.
    It includes diagnostic tests, follow-up treatments, medical consultations, medication, and other related expenses. Health insurance policies typically cover these medical costs for 45-90 days after hospital discharge.

Types Of Hospitalisations That Can Be Claimed Under Health Insurance:

A health insurance claim is a formal request made by an individual who holds a health insurance policy, asking their insurance provider to cover the costs of medical services and benefits specified in their policy. This claim can be submitted for different types of hospitalisations:

Planned Hospitalisation
Planned Hospitalisation

A planned hospitalisation refers to a situation where the policyholder is aware of their upcoming hospital stay in advance. Typically, it is necessary for treating a pre-diagnosed illness or medical condition. In such instances, the policyholder must notify the insurance company about the planned hospitalisation at least 48 hours before their admission.

Emergency Hospitalisation
Emergency Hospitalisation

An emergency hospitalisation refers to a sudden and unplanned admission to a hospital. Usually, emergency hospitalisation becomes necessary when the insured individual is involved in an accident and requires immediate hospital care. In such instances, the insured person’s family is instructed to contact the health insurance provider within 24 hours of the patient’s admission to the hospital.

Things To Keep In Mind To Avail A Health Insurance Claim:

Health insurance is a vital protection plan to save lives and ensure financial stability during medical issues. With the increasing cost of healthcare, it is essential to consider the efficiency of the claim settlement process when purchasing a health insurance policy. It is advisable to always check the settlement ratio of insurers before claiming a health insurance plan. Here are some crucial aspects to consider while filing the health insurance claim:

  1. Validity Of Health Insurance:
    It is crucial to remember that you can only submit a health insurance claim if you have a valid medical insurance plan. If your plan has expired and you still need to renew it, the insurance company will not consider any claims made on that plan. Therefore, it is essential to be aware of your medical insurance plan’s validity and ensure to renew it on time.

  2. Included And Excluded Terms And Conditions:
    It is crucial to thoroughly review and understand the inclusions and exclusions of your health insurance plan. Reading the entire policy document and taking note of these details is essential to comprehend the extent of your coverage entirely. Additionally, this process helps you choose the most appropriate health insurance plan for yourself and your family.

  3. Waiting Period And Coverage Terms Of Health Conditions:
    While certain illnesses are included in a standard health insurance policy, others are not. For example, all medical insurance plans may not cover pre-existing conditions and serious diseases. Even if these illnesses are covered, there may be a waiting period before the coverage takes effect.

    Therefore, obtaining a health insurance plan that covers it explicitly is advisable if you have a pre-existing condition. Additionally, you can enhance your coverage by purchasing an additional medical insurance add-on for critical illnesses.

  4. Other Important Details:
    When filing health insurance claims, it is crucial to remember certain additional information. If the cashless pre-authorisation request is filed correctly, it may be allowed. It is vital to inform the insurance company about your hospitalisation as soon as it occurs.

    All reimbursement claims must be submitted within 20 -30 days of discharge from the hospital. To claim post-hospitalisation expenses, the policyholder must provide all relevant documents within the specified time limit set by the insurer.

Health Insurance Claim Process:

The main objective of a health insurance plan is to offer financial aid for medical services. Individuals must submit a health insurance claim to receive this assistance when necessary. There are two types of claims that policyholders can file.

Here are the details:

  1. Cashless: In this claim, the insurance company takes responsibility for paying all the medical expenses directly to the hospital. However, the insured individual must be admitted to a hospital within the network to receive the advantages of cashless hospitalisation.
  2. Reimbursement: In this procedure for making a claim, the policyholder is responsible for paying the hospitalisation costs directly when they leave the hospital and then seeks reimbursement from the insurance company afterwards. Requesting reimbursement for expenses incurred at the network and non-network hospitals is possible.

For Both Planned And Emergency:

Here is the process of filing the planned and emergency health insurance claim. Below are the details:

  1. Planned:
    The process for obtaining a planned hospitalisation claim under a health insurance policy needs the following steps:
    1. To be admitted to a hospital as part of your insurance company’s network, please get in touch with the insurance helpdesk.
    2. Present the identification health card issued by your insurer for verification purposes.
    3. The hospital will confirm your identity and provide a pre-authorisation form for treatment without needing cash payment.
    4. Complete the pre-authorisation form and hand it in at the insurance counter.
    5. Your health insurance provider will receive the pre-authorisation form from the network hospital.
    6. The insurance company will assess your pre-authorisation request and associated paperwork and grant approval for your cashless claim based on the terms and conditions outlined in your health insurance policy. In some cases, insurers may even provide a selected field doctor to simplify the process of approving cashless claims.
    7. When you are ready to leave, make sure to settle the medical costs that are not included in your health insurance plan.
    8. According to the terms and conditions of your policy, the hospital will receive the claim amount directly from your insurance company.

  2. Emergency:
    To file a claim for emergency hospitalisation under your health insurance policy, please follow the steps provided below:
    1. It is essential to quickly inform your health insurance provider about your hospital stay.
    2. Take medical care at the hospital.
    3. Settle the complete hospital expenses and gather all the necessary paperwork at discharge.
    4. Please ensure you provide all the necessary paperwork to your health insurance provider.
    5. The insurance company will carefully examine all the documents you have submitted and manage your claim according to the terms and conditions outlined in your health policy.
    6. Once your claim is authorised, payment for the claim will be issued to you.

Claim Intimation:

If you require a scheduled treatment, it is vital to inform the insurance company in advance. This notification should be made at least 3 to 4 days before hospitalisation. You must complete and submit a pre-authorisation form to the insurance company, which serves as a notification for your claim.

The form should be completed and submitted 3 to 4 days before planned hospitalisations. In a medical emergency where immediate hospitalisation is necessary, informing the insurance company and submitting the pre-authorisation form within 24 hours of being admitted is crucial.

Claim Status Check:

The most effective method to verify the progress of a health insurance claim is to contact the claim support team or access the website of your insurance provider. You could also get their claim assistance team if you obtain your policy through the insurance website portal. Another option is to visit the health insurance claim page to obtain information about the status of your claim.

Documents For Health Insurance Claim:

  1. Hospitalisation Claim:
    Below is the given list of documents necessary for filing claims for planned and emergency hospitalisation claims:
    1. Original claim form attested with your signature.
    2. Identity proof
    3. Prescription of a doctor confirming the hospital treatment
    4. Treatment ensures consultation, diagnostic tests, and medicines.
    5. Internal case papers
    6. Ambulance papers
    7. Original pharmacy bills with seals
    8. Policy details include policy number, insurer’s name, address, and medical conditions and treatment.
    9. Additional verifying documents (if needed).

  2. Hospitalisation Death Claim:
    Here are the documents required for filing the hospitalisation death claim:
    1. Original claim form attested with nominee sign
    2. Identity proof
    3. Original Death certificate.
    4. Internal case papers
    5. Ambulance receipt
    6. Actual pharmacy bills with seals (in case required)
    7. First Information Report (FIR) (as required)
    8. Policy details include policy number, name of the policyholder, address, and medical conditions and treatment.
    9. Additional verifying documents (if needed).

  3. Personal Accidental Claim:
    The essential documents needed to file the accidental claim are:
    1. Complete Policy Papers with insurer and insurance company details
    2. Complete the claim form with your signature
    3. Doctor’s Consultation
    4. Cancelled cheque with account details for the transfer of the reimbursement
    5. KYC papers
    6. Bills and receipts of medication prescribed by a doctor
    7. Original invoices and reports of medical tests such as X-rays, CT scans, Blood Reports, Ultrasound, etc.
    8. Copy of FIR/Medico-Legal Certificate with details of the accident
    9. Discharge summary.
  4. Critical Illness claim:
    The critical illness claims need the below-listed documents:
    1. Health Card issued by the health insurance company
    2. Complete consultation records of doctor and specialist
    3. Properly filled in and signed the claim form
    4. Original examination and diagnosis reports like MRI, CT scans, blood reports, etc.
    5. Original hospital bills and payment receipts with hospital seal
    6. Original pharmacy invoice and payment receipts with prescribed medication.
    7. Complete discharge summary
    8. Additional documents if needed.
  5. Claim for daycare procedures:
    Here are the documents necessary to claim health insurance for daycare procedures:
    1. Original health insurance documents.
    2. Original consultation and diagnosis papers with doctors’ prescription
    3. Filled claim form with your signature.
    4. Consultation, medical tests, and hospital bills with original payment receipts
    5. Pharmacy bills with original receipts
    6. Overall discharge summary
    7. Additional details, if needed.
  6. Pre And Post Hospitalisation Claim:
    The pre and post-hospitalisation claim requires:
    1. Valid health insurance card
    2. Necessary OPD consultation papers of doctor
    3. Claim form filled with required details and signature
    4. Medical test and diagnosis reports of tests like ECG, CT scans, Ultrasound, X-rays, urine and blood reports, etc.
    5. Original hospital bills with sealed and signed payment receipts
    6. FIR (in case of accidents) or Medico Legal Certificate (MLC) (if required)
    7. Original Pharmacy bills with payment receipts
    8. Hospital discharge details with doctors’ sign
    9. Additional documents, if needed.

How To Claim From Multiple Insurers?

If you have health insurance coverage from multiple insurers, you can file a cashless claim with one insurer to cover all your medical expenses. After the first insurer settles your claim, you can approach the second insurer to cover the remaining costs.

To do this, you will need to provide the second insurer with the claim settlement summary from the first insurer and the verified hospital bills and payment receipts. The second insurer will assess your claim based on the terms and conditions of your policy and reimburse you accordingly.

Reasons Why Health Insurance Claims May Get Rejected And How To Avoid the same:

Here are some of the most general details that can result in rejecting health insurance claims.

  1. If you have not provided the information about any pre-existing medical conditions when purchasing the policy.
  2. If the insurance company finds any fraudulent details in your claim.
  3. When you submit a request for reimbursement for medical procedures or illnesses that are not included in the health insurance plan.
  4. If you file the claim during the waiting period.
  5. The claim is raised after the health insurance is expired.
  6. In case you fail to submit a claim within the specified time.
  7. If a claim is made for an amount greater than the sum insured stated in the policy.

Frequently Asked Questions

Many insurance companies manage claims without the requirement of cash payments. However, it is advised to the policyholders to refer to their policy document to understand whether the company settles claims in a cashless manner or through reimbursement. Even if cashless claims are applicable, receiving treatment at a hospital affiliated with the insurance company's network is essential.

Your insurance policy includes a waiting period for 30 days before you can file a claim unless it is due to an accident. There are also waiting periods for pre-existing conditions and specific diseases, which can vary depending on the terms and conditions of the insurance company. To avoid any unpleasant surprises at the time of settling your claim, it is recommended that you contact your insurance provider and inquire about the waiting periods.

A Third-Party Administrator (TPA) is a mediator that assists in settling claims between the insured party and the insurance company. TPAs can be found at hospital reception desks and are the primary contact for customers to inform the insurance company about their claims.

You can make a claim on your health insurance policy once you have been hospitalised or received treatment. In the case of emergency hospitalisation, you must notify your insurance company within 24 hours, and for planned hospitalisation, you should inform them at least 48 hours beforehand. To receive reimbursement, you must provide all the required documents to your insurer within 30 days of discharge.

You can file multiple health insurance claims without restrictions during the policy period. However, ensuring that the total claim amount does not exceed the sum insured is essential. If the total claim amount exceeds the sum insured, you will be responsible for covering the additional expenses.

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