The procedure for filing a claim against your health insurance policy can vary depending on the policy you have purchased. Indemnity plans and defined benefit plans are the two most common types of health insurance policies. An indemnity-based plan reimburses the policyholder for real expenses incurred up to the policy’s cum-covered limit. A defined benefit plan, on the other hand, pays a fixed sum insured amount regardless of the cost.
How Do I File A Health Insurance Claim?
When a claim is filed, it is the moment of truth for any insurance policy, particularly health insurance. The purpose of purchasing a health insurance policy is to ensure that you are not concerned about the financial expense of treatment in the event of a medical emergency or when seeking medical treatment. It is equally crucial to understand the health insurance claims process as it is to acquire adequate health insurance coverage so that you can rely on your health insurance policy in times of need.
Consider a few factors before purchasing health insurance. It is important to remember that the plan kicks in if you are hospitalized or need to pay for medical reasons. Only if your medical condition is covered by the policy will the health insurance manage your claims, so read the fine print carefully. Choosing a little more expensive plan with better coverage over the cheapest choice with limited coverage is preferred.
Health insurance policies allow two types of claims. These are the following:
- No-cash claims
- Reimbursements
Cashless claims
The most important feature of cashless claims is how simple and quick they are to handle. Most insurance companies have affiliations to a network of hospitals, and if you choose a partner hospital for treatment, you can use the cashless claim option. You wouldn’t have to pay anything if you filed a cashless claim since the insurance company would settle the claim straight with the hospital. This implies that you can receive treatment at any of the network hospitals, and the insurance company will cover all of your expenses without you having to pay anything out of pocket.
The Procedure for Filing a Cashless Claim
1. Most network hospitals will have a specialized insurance desk in place. You may get the form here.
2. You can request the form from the insurance company’s claims department by contacting them directly via email or toll-free phone number.
3. To obtain and print the form, go to the TPA’s (Third Party Administrators) website. A third-party administrator (TPA) is hired by the insurance company to manage claim-related procedures on its behalf. A TPA must be licensed by India’s Insurance Regulatory and Development Authority (IRDAI).
The filled-out form must be returned to the hospital’s insurance desk. Once you’ve filed your form, the TPA will review it and send you a sanction letter outlining the maximum amount that has been approved for your treatment.
Notify the firm and submit the form within 24 hours after being admitted to the hospital in the event of a medical emergency. The company will analyze the claim and proceed with the process after receiving it.
Claims for reimbursement
Under the reimbursement option, you must first pay the bills, and then the insurance provider will reimburse you for the money you spent, according to the original hospital bills, once the claim is processed. This will almost certainly be more inconvenient than a cashless claim. However, you are not required to seek medical assistance just at a network facility. You have the option of going to any hospital you like.
Steps to Filing a Claim for Reimbursement
All essential documentation should be kept and submitted. The most important documents you’ll need when filing a refund claim are listed below.
1. The claimant completed and signed the claim form. This form is available for download online or at the insurance company’s office.
2. Your admission and discharge certificate, summary report, case file, and any other related documents. All of this paperwork must be signed by your case doctor at the hospital.
3. All of your original prescription bills, cash memos, and receipts.
4. If the medical care you received was a result of an accident, you must also attach a copy of the First Information Report (FIR) you filed with the police. If an FIR is not accessible, you must provide a Medico-Legal Certificate.
Following an evaluation of the documents and in accordance with the policy’s coverage, the insurance company will reimburse you for the expenses incurred during your hospitalization.
