Here’s how claim process Works for these health insurance covers.
Claim Process for Indemnity Plans
Most of the original mediclaim policies are covered under indemnity plan. Amit Chhabra, Head – Health Insurance, Policybazaar.com says, “By the name go, indemnity-based health plans basically indemnify the policyholder for hospitalization expenses up to the total sum insured.” There are two ways in which you can make a claim against these policies – cashless and reimbursement mode.
Cashless Mediclaim Process: Cashless claim is the process in which the claim amount is paid directly to the hospital by the health insurance company. This facility is available only if you visit a hospital with which the insurance company has prior understanding of providing cashless claims service. These are called empaneled or network hospitals which provide cashless claims service.
However, a cashless plan does not mean that there will be no cost to the policyholder. There are certain costs like consumables which may not be covered under the policy; This has to be paid by the policyholder. “If the insured has opted for a cashless hospitalization plan, then the insured will only have to pay a certain amount and the rest is taken care of by the insurer,” says Chhabra.
There are two types of cashless plans based on the nature of hospitalization. Nayan Goswami, Head (General Insurance), Sanaa Insurance Brokers says, “Planned hospitalization is done when you know about hospitalization in the near future and you can check with your insurer for pre-hospitalisation before hospitalization. authorization can be obtained.” This happens mostly in cases of planned surgeries, where you have enough time to get pre-authorization before you are admitted to the hospital.
However, on many occasions, the insured may require immediate hospitalization. Goswami says, “Emergency hospitalization is done when the insured becomes an accident victim or suffers from any ailment that requires immediate hospitalization – an emergency.” In such cases authorization is sought after the patient is admitted.
“The basic claims process works the same way for both corporate and individual individual plans. In corporate claims the HR of the organization can help liaise with the insurer or TPA. Insurance brokers also offer help. But cashless claims For, it doesn’t really require much intervention and the hospital does most of the work,” says Goswami.
While some insurers have their own claim processing arrangements with hospitals, many others have third party administrators (TPAs) to coordinate their claim processing with hospitals. In this case, you have to contact the TPA helpdesk at the hospital and show them your health card along with the doctor’s advice for hospitalization. “They will fill up a cashless form which you may need to sign. Most of the forms, the hospital will fill, may require you to fill in some personal details. The hospital will send a pre-authorization request to the concerned insurer for TPA helpdesk approval. Approval It usually takes 30 minutes to 4 hours,” says Goswami.
You need to carry any Government ID like Aadhar Card, Driving License etc. If the patient is an employee or dependent of the policyholder, some hospitals may also ask for ID proof of the policyholder. Sometimes hospitals insist on the policy holder’s PAN card, which is usually required when the claim amount exceeds Rs 1 lakh.
Reimbursement Mode Claim Process: “Reimbursement claims are claims where you make an advance payment of hospitalization expenses and request the insurer for reimbursement after discharge. You can avail reimbursement facility in both network and non-network hospitals. You will need to send bills and other documents (that you receive from your hospital at the time of discharge) to your insurer for reimbursement within 15 days of discharge,” says Goswami.
In order to conduct the reimbursement claim, there are different timelines given by the insurance companies to the insured. Naval Goel, Founder and CEO, PolicyX.com, an IRDA-approved insurance comparison portal, said, “If a patient is going for planned medical treatment, the policyholder will be informed about the medical treatment and hospital details 2 days prior to admission. Have to do it.” ,
If you do not get time to notify the insurer due to an emergency, you should do so immediately after you are admitted to the hospital. Goyal says, “If the policyholder is admitted to a non-network hospital in an emergency, the insured should be informed within 24 hours of the admission and informed about the health condition and claim. ”
If this is not possible then you have a third option; You can do this after you get discharged. “If a policyholder is planning to file a reimbursement claim after being discharged from the hospital, the claim should be filed between 7-15 days after being discharged from the hospital,” says Goyal.
How to claim reimbursement for pre and post hospitalization expenses
Most health plans cover not only hospitalization expenses, but also related expenses that occurred prior to hospitalization and after being discharged from the hospital. “As per the rules, the insurer has to reimburse the expenses for about 30 days before hospitalization and 60 days after discharge,” says Goyal.
If your entire claim is through reimbursement mode then you can cover this expense while making the claim.
However, if it was cashless hospitalization, you may have to claim this reimbursement separately. “The bills of medical expenses related to the illness for which the insured was admitted need to be submitted to the insurer or the appointed TPA as per the terms and policies of the insurance company. After verification, the insurer will be required to submit the applicable pre-hospitalisation Will reimburse the hospitalization and post-hospitalization costs within a specified period,” says Rakesh Goel, director, Probus Insurance Brokers.
Don’t forget to check sub-limit usage
Just having an overall higher sum insured may not be enough as many health plans come with low sub-limits for any medical condition. To avoid any last minute surprises, it would be better for you to check if your policy has any sub-limits for the specific medical condition that required hospitalization. “The sub-limit should be checked as it can reduce the claim amount. Since there is a cap on specified conditions like room rent, treatment for certain diseases, or post-hospitalization charges, the policyholder can only pay a sub-limit. One can claim for the amount below the limit,” says Goyal.
On most occasions network hospitals will be able to keep expenses around this sublimit but in case of any complications or longer stays, expenses can go beyond the sublimit. “If you know the sub-limit, it helps to keep expenses under control by making sure the room rent isn’t high or the cost of treatment isn’t justified,” says Goyal. If there are more policies, you can use another policy accordingly to pay for the additional expenses.
Time taken to receive payment against reimbursement claim
The time taken for a reimbursement claim is often longer as compared to a cashless claim which is often without a few hours. So to expedite the process, you need to file a reimbursement claim at the earliest.
“When the policyholder is admitted to an out-of-network hospital, he has to pay for the entire treatment. After discharge, the policyholder can submit all relevant documents within 7-15 days,” says Goyal.
Once you submit the claim, it will take a few weeks for the insurer to process your claim. However, on many occasions, the process of clarification of the queries raised by the claims department may take a long time. “The whole process takes a maximum of 21 days to settle the reimbursement claim as the insurance company or TPA (any route that the policyholder follows), verify the documents, reports, bills, diagnosis reports etc. If any There is confusion or ambiguity in the bill or report, the insurance company/TPA returns to the policyholder for clarity. If not, the claim is settled within 21 working days,” says Goyal.
Claim Process for Defined Benefit Plans
Major surgical benefit policies and critical illness plans come under defined benefit health insurance plans that pay a fixed amount on the occurrence of an event like diagnosis of the disease covered with specific severity. Many life insurers also offer these health plans as a rider with their life insurance policies. According to Kotak Life Insurance website, in case of a critical illness claim, the rider sum assured will be paid if the insured is diagnosed to be suffering from any of the ailments specified in the policy contract and if the criteria for claiming rider benefit are are satisfied.
Hence, once you are sure about the coverage benefit you can file a claim after completing all the documents or you can inform the insurer in advance about your plans to claim.
According to HDFC ERGO’s website, in case of claim under critical illness cover, you should immediately inform them on their helpline numbers. On receipt of the intimation, the insurer will register the claim and provide a unique claim reference number which will be communicated to the insured which can be used for all future correspondence.
According to Kotak Life’s website, the mandatory documents that the beneficiary needs to submit to make a claim include a duly filled rider claim information form, original policy document, photo of the insured, present address proof, photo ID proof and Contains medical records, including consultation notes, treatments. Records, Admission notes, Case papers inside the hospital, Discharge summary, Test reports etc. The insurer may also ask for some supporting documents such as a copy of the life insured’s bank passbook or statement with bank account details.