Health Insurance Claims
A health insurance plan comes into effect when the insured is hospitalised or when the insured faces a medical contingency and incurs cost. At that time, if the hospitalisation or the medical expenses are covered by the health insurance plan, a health insurance claim is said to occur. Under a health insurance claim, the insurance company pays the medical expenses which incur in case of any medical contingency.
Types of health insurance claims
There are two types of claims admissible in a health insurance policy. These are as follows:
Let’s understand the meaning and the processes involved in both these types of claims.
Cashless settlement of health insurance claims occurs when the insured seeks treatment in a networked hospital. A networked hospital is one which is tied-up with the insurance company. Since treatments are taken at a networked hospital, the insurance company settles the hospital bills directly with the hospital. You, therefore, do not have to take the burden of paying for the medical expenses yourself.
Here are the steps involved in availing a cashless claim settlement
- If you are seeking a planned treatment, inform the insurance company beforehand. Intimation should be given at least 3 to 4 days prior to being hospitalised. A pre-authorisation form needs to be filled in and submitted with the insurance company. This form acts as a claim notification. In case of planned hospitalisation, the form should be filled in and submitted 3 to 4 days in advance.
- If there is a medical emergency and the insured is being hospitalised under an emergency situation, the insurance company should be informed and the pre-authorisation form should be submitted within 24 hours of hospitalisation.
- Once the pre-authorisation form is submitted, the insurance company assesses the claim based on the form and allows cashless claim settlements.
- The insured can then avail the required treatments without paying the medical bills incurred.
- All medical bills, medical reports and other medical documents should be submitted to the insurance company.
- If there are other expenses which are being covered, original documented proofs of such expenses should also be submitted with the insurance company.
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Reimbursement claim happens when the insured pays for the medical bills himself and then gets the expenses reimbursed from the insurance company. Reimbursement claims occur if the insured avail treatments at a non-networked hospital or if the insurance company does not allow cashless claim settlements.
Here are the steps involved in availing reimbursement of your health insurance claims
- The insured would have to get admitted in a hospital which is not tied-up with the insurance company and avail treatments.
- All the original medical reports and bills should be retained by the insured. The medical bills should also be paid out of the insured’s own pockets.
- After being discharged from the hospital, the insured should avail a Discharge Certificate or Discharge Summary from the hospital from which treatment was availed.
- This Discharge Certificate or Summary should be, then, submitted with the insurance company along with a duly filled in claim form, medical reports and bills in original and other relevant documents which the insurance company requires.
- The insurance company would, then, analyse the claim, the related documents and the expenses incurred. The expenses would then be reimbursed.
5 key Factors to Understand Claim Settlement Ratio in Health Insurance
Claim settlement ratio refers to the percentage of claims resolved and settled by an insurance company in comparison to the number of claims raised at the company. When it comes to health insurance, one of the most striking features of a health insurance company is considered to be its health claim settlement ratio. It reveals the capability of a company and how helpful it can be in solving your financial issues that occur during a health crisis. So far you can understand that the higher the claim settlement ratio the higher is your chances to get aid on time. Now, how can you understand the claim settlement ratio regarding a specific company? Here are five key factors to consider in this context:
- Comprehensive Calculation
Claim settlement ratio is not something specific about one product offered by an insurance company. For instance, a life insurance company with a 95% of claim settlement ratio has different things calculated together. It includes term plans, ULIPs, health plans, motor insurance and many more. Putting together all these parameters, the claim settlement ratio is calculated. Hence, it is a comprehensive calculation.
- Consistency is the Key
Fortnight success may not be forever reliable. When you plan to get a health insurance plan, you need to check the claim settlement ratio of the particular company. Now, the smartness lies in going through its CSR of at least 5 preceding years as well. If there is a consistent ratio with nominal changes in the past 5 years, you can rely on the company with expecting a somewhat same result in the coming policy year as well. However, if the current CSR is too high and the previous ones are low, you must make a thorough check without relying only on the current CSR.
- Rely on an authentic source
There may be several websites and companies that may be publishing claim settlement ratios for competitive companies for one policy year. However, it is important to rely on strong and reliable sources. IRDAI publishes the Incurred Claim Ratio of both private and government companies every year. From their chart, you can easily track the facts for each company and compare and decide accordingly.
- History Matters
You need to check the background of the company, how long has it been functioning, the number of claims settled by the company, etc. Public reviews also matter a lot in deciding whether or not a company is suitable for your requirements.
- Choose CSR over low-premium
Lower premiums may sound attractive. However, if you get to compromise on CSR to get a lower premium rate, it might not be the move of a wise man. To decide easily, you can shortlist companies who offer high CSR, for instance, 90% and above. Among these companies, you can go for the one offering the lowest premium rates.
Points to remember
There are certain important points which the insured should be careful about at the time of health insurance claims. These points help in speedy and smooth claim settlement. The points are as follows:
- Documents required
Besides the pre-authorisation form and the original medical bills and reports, other important documents would also be required at the time of making a claim. These include the following
- A valid ID proof of the insured
- Bills of any equipment used in the operation
- Copy of the policy bond
- Cancelled cheque
- Any other documents as required by the insurance company
- The sum insured limit
Health insurance claims are admissible only up to the sum insured limit availed by the insured. If the claim exceeds the sum insured, the excess would have to be paid by the insured. So, the insured should check the sum insured limit of the health insurance policy.
There are some instances which are not covered by health insurance plans. These are called exclusions. If a claim is made for an excluded expense, the claim would be rejected. So, the plan exclusions should be checked before making a claim so that a claim for an excluded expense is not made. Even if the claim is made and subsequently rejected, the insured would know the reason for rejection.
There is a timeline for submission of the pre-authorisation form in case of a cashless claim. In case of planned hospitalisation, the pre-authorisation form should be submitted 3-4 days in advance while in case of emergency hospitalisation, the form should be submitted within 24 hours. Compliance of these timelines is necessary to avail cashless claim settlements. If the timelines are not followed, the claim might get delayed.
- List of networked hospitals
A cashless settlement of claim is possible only if treatments are availed at a networked hospital. So, if the insured wishes to avail cashless claim service, the list of tied-up hospitals should be checked before seeking treatments. The list is easily available at the insurance company’s website and can be checked online.
- Validity of the insurance policy
Health insurance claims are settled only if the health insurance policy is valid and not lapsed. If the policy has been lapsed, the claim would be rejected. So, the insured should ensure that the policy continues without lapse to enjoy easy claim settlements.
Steps to file Health Insurance Claim Form
Filing a health insurance claim is important in order to avail the benefits of the health insurance and lower your financial burden. It is not a tough task to get financial aid from your insured company as long as you follow the process. Follow the simple guide below to understand how to file cashless and reimbursement claims:
- Step 1:
Collect all your medical reports, bills, and receipts for which you want to file a claim and arrange them in chronological order. (Make sure all the medical documents have the necessary details like the patient’s name, cost price, serial number, the signature of the doctor, stamp, etc.)
- Step 2:
You need to attach a claim form. You can get it either from the insurance company’s office or download and print it from their official website.
- Step 3:
Read the form and instructions given and fill in all the details properly. Get the signature of the policyholder and resting consultant on the form.
- Step 4:
In the next step, you need to attach a few policy and medical documents to complete the form. The documents needed:
- Patient’s treatment documents
- The discharge summary from the hospital
- Patient’s medical/ investigative reports
- A recovery certificate of the patient from the medical practitioner
- TPA (Third Party Administrator) Card. You can know about it by visiting the TPA branch of your health insurance company
- NEFT details for the reimbursement
- Step 5:
Make a copy of the claim documents and submit the file to the executive present at the TPA office. Submit one copy to your health insurance company as well and inform them about the submission of your claim form.
How to Check Health Insurance Claim Status?
Keeping a tab on the status of your health insurance claim is essential. It is quite easy to check the status via both online and offline modes. Almost all health insurance company have their official website. From there, you can go to the claim section, provide certain details like claim number, customer ID, etc. and check the status. Also, if you wish, you can visit the branch of the company with relevant details and documents and get to know your health insurance claim status.
Common Reasons for the Rejection of Health Insurance Claim
You must have heard people complaining about their health insurance claim being rejected. Have you wondered what are the reasons for this rejection? Here are some common mistakes that can lead to the rejection of the claim form which you should refrain from committing in order to get the desired assistance from your health insurance company:
- Incomplete Process:
The very basic and common mistake that you might do is filing an incomplete form. Every health insurance company has their own set of rules and you must know about it properly before filing a claim. If you have doubts, connect with an executive from your health insurance company. If you submit an incomplete form or go out of the process of the company, the form may get rejected.
- Know what’s not covered:
Some of the insurance companies are not able to provide you with financial assistance for pre-existing diseases that you might have before purchasing the policy. For instance, if you have diabetes before purchasing the policy and in future, if you file claims for expenses incurred on the treatment of diabetes, your form will be rejected.
- Expired policy:
Most health insurance company has a policy year of 12 months. After one year, the policy expires. So, you must be aware of the expiry date of your policy and get it renewed on time or else it will lapse. If you file a claim after your policy has expired, your claim form will get rejected.
- Know about the waiting period:
When you read the terms and conditions of a health insurance policy, you might find them mentioning about waiting period. For instance, a health insurance company requires a waiting period to disburse maternity aid. So, if you file a claim during the waiting period, your form will be rejected.
- Exclusions are crucial: Not everything is covered in one health insurance plan. There might be a few exclusions including pre-existing diseases. So, if you file a claim for a disease that is not covered by a particular health insurance company, the claim form will be rejected.
These are some of the facts regarding the claim settlement ratio of a health insurance company which you must be aware of. When choosing a health insurance plan, make sure you pay heed to the CSR of a company and check all the other details before purchasing. When you plan to file a claim, make sure you go with the correct procedure and refrain from making a wrong claim.
How to file a health insurance claim through Turtlemint?
Turtlemint is an online platform which not only allows individuals to buy a health insurance policy easily, it also allows speedy settlement of health insurance claims. Turtlemint has a dedicated claim settlement department which helps customers get settlement of their health insurance claims. To file a claim through Turtlemint, the following steps should be followed:
- Inform Turtlemint immediately in case of a claim. For planned and emergency hospitalisations, the prescribed timelines should be followed.
- Turtlemint then informs the insurance company and forwards the pre-authorisation form for approval.
- Turtlemint co-ordinates and follows-up with the insurance company regarding the status of claim settlement.
- The insurance company then settles the claim, whether it is cashless or through reimbursement.
Turtlemint, therefore, ensures that all proper documentation regarding the claim is completed and the claim is easily settled by the insurance company. The customer, therefore, is spared the burden of following up with the insurance company at regular intervals.
Most insurance companies settle claims in a cashless manner. However, the insured should check the policy document to understand whether the company settles the claims in a cashless manner or through reimbursement. Even in case of cashless claims, treatments must be taken at a networked hospital.
The Discharge Summary and the original medical bills are necessary for getting the medical expenses reimbursed under a reimbursement claim.
A TPA is a Third Party Administrator which facilitates claim settlement between the insurance company and the insured. TPAs are available at the hospital reception desks. They form the point of contact for the customer through which the customer can intimate the claim to the insurance company.
Many insurance companies allow in-house claim settlement. Under this, there is no TPA. The insurance company handles the claims internally. This allows speedy claim settlements.
In case of claim rejection, the insured should find the reason of rejection. If it is a justified reason, the claim would not be paid. However, if the insured believes that the claim is admissible, a complaint can be lodged with the insurance company’s grievance redressal cell.
Yes, a health insurance claim can be settled from multiple insurance companies. All the insurance companies should be informed in case of a claim and the relevant documents should be submitted with each insurer.
If the claim is not intimated to the insurance company within the prescribed timelines, the insurance company would require additional time for claim settlement. This would get the claim delayed. Moreover, the claim might also be rejected if it is intimated after a long time.