Types of Health Insurance Claims:

Types of Health Insurance Claims

1. Cashless Claims:
   • In this process, the insured individual receives medical treatment at a network hospital (a hospital that has a tie-up with the insurance company).²
   • The insurance company directly settles the eligible medical bills with the hospital, so the policyholder doesn’t have to pay upfront for covered expenses (except for any deductibles or non-covered items).³
2. Reimbursement Claims:
   • In this case, the insured individual can seek treatment at any hospital (network or non-network).
   • The policyholder initially pays the medical bills out of their own pocket and then submits a claim to the insurance company for reimbursement of the eligible expenses.⁴

Steps for Cashless Claim Settlement:

1. Hospitalization:
   • Planned Hospitalization: Inform the insurance company well in advance (usually 48 hours prior).⁵ Some insurers may require pre-authorization for planned treatments.
   • Emergency Hospitalization: Inform the insurance company as soon as possible, typically within 24 hours of admission.
2. At the Network Hospital:
   • Visit the insurance/TPA (Third Party Administrator) desk at the hospital.
   • Show your health insurance card and a valid photo ID for verification.
   • The hospital will provide a pre-authorization form. Fill it out and submit it along with the required documents (policy copy, doctor’s consultation papers, etc.).
3. Pre-authorization by the Insurer:
   • The hospital will forward the pre-authorization request and documents to the insurance company/TPA.
   • The insurer will review the request and the policy terms and conditions to approve the cashless claim for a specific amount.
4. Treatment and Discharge:
   • Once the pre-authorization is approved, you can undergo the necessary treatment.
   • At the time of discharge, the hospital will prepare the final bill and send it to the insurance company for direct settlement (up to the pre-authorized amount and as per policy terms).
   • You will only need to pay for any non-admissible expenses or the amount exceeding the approved limit.

Steps for Reimbursement Claim Settlement:

1. Hospitalization and Treatment:
   • You can get treatment at any hospital.
   • Pay all the medical bills upfront at the time of discharge and ensure you collect all original bills, receipts, discharge summary, investigation reports, and other relevant medical documents.
2. Intimation to the Insurer:
   • Inform the insurance company about your hospitalization as soon as possible (usually within a specified timeframe, e.g., 7-15 days of discharge).
3. Claim Form and Document Submission:
   • Download the claim form from the insurer’s website or obtain it from them.
   • Fill out the claim form accurately and attach all the original medical bills, reports, discharge summary, pharmacy bills, doctor’s prescriptions, and any other documents specified by the insurer.
   • Submit the completed claim form and documents to the insurance company within the stipulated time frame (usually 15-30 days from the date of discharge).
4. Claim Processing and Reimbursement:
   • The insurance company will review the submitted claim form and documents.
   • They may conduct a verification process, which could involve communication with the hospital or you.
   • If the claim is approved as per the policy terms and conditions, the insurer will reimburse the eligible amount to your bank account (NEFT details usually need to be provided).
   • The claim settlement timeframe can vary but is often around 15-30 days after receiving all the necessary documents. IRDAI guidelines mandate that claims should be settled within 30 days of receiving the last necessary document.

Key Documents Generally Required for Health Insurance Claims:

• Duly filled and signed claim form.
• Original hospital bills with a detailed breakdown.
• Discharge summary from the hospital.
• Doctor’s prescriptions for medicines and tests.
• Original pharmacy bills.
• Investigation reports (X-rays, blood tests, etc.).
• Medical certificate from the attending doctor.
• Policy copy.
• ID proof of the policyholder/patient.
• Age proof.
• Address proof.
• Bank account details (for reimbursement).
• FIR or Medico-Legal Certificate (MLC) in case of accidents.

Important Points to Remember for a Smooth Claim Process:

• Timely Intimation: Inform the insurer about hospitalization within the specified timeframe.
• Accurate Information: Provide correct and complete details in the claim form and all other documents.
• Original Documents: Submit original bills and reports for reimbursement claims.
• Policy Terms and Conditions: Be aware of your policy’s inclusions, exclusions, waiting periods, and sub-limits.
• Network Hospitals: For cashless claims, ensure you are admitted to a network hospital.
• Pre-authorization: For planned treatments at network hospitals, obtain pre-authorization.
• Claim Tracking: Keep track of your claim status through the insurer’s website, mobile app, or customer care.
• Disclosure of Pre-existing Conditions: Disclose all pre-existing conditions at the time of policy purchase to avoid claim rejection later.

Understanding these steps and keeping the necessary documents ready can help you navigate the health insurance claim settlement process efficiently during a medical emergency.