How Does Health Insurance Claim Process Work?

Your insurance provider offers either a Reimbursement Process or a Cashless Claim Process. But how do you approach these processes if you are not aware of how do they work? Read on to understand the nuances of the claims.

1) Cashless Claim Process

Cashless, as the name recommends, frees you from the pain of handling cash in bulk. So how do you pay the bills? As an insurance provider, you become liable to provide your insurance details to the hospital in order to avail their facilities. It could be with the help of physical proof or even an e-card which is issued during the mediclaim policy purchase. Based on these proofs only, the hospital accepts your request to treat you and process the claims accordingly. However, the illness for which you have been admitted requires that that disease is covered under your insurance plan. After you are discharged from the hospital, it is the responsibility of the hospital to forward all the bills to the insurance provider.

As soon as these bills are received by the hospital, the bills are scrutinized thoroughly by the respective departments to understand the nature of the expense, and settle the payment such that all dues are cleared. This process is known as a cashless settlement where payment instruction flows between the hospital and the insurance provider. As an insurance holder, you do not have to keep track of the bills physically or stress about how to pay the medical bills.

But as an insured citizen, how do you go about the claim anyway? Well, there are a couple of methods which can be kept in mind when you face such a dilemma.

If you know that it is going to be a planned event

Sometimes, doctors inform you prior to the surgery that you would need to undergo one. It could be any treatment for a matter of fact which needs prior preparation. Under such circumstances, you can always give your insurance provider heads up at least 4 days prior to seeking treatment at the network hospital. However, the time frame varies from provider to provider. That is not the end of it. As an insurance holder, you need to submit a cashless claim form to the provider physically or through electronic media such as email or fax. The post is also widely accepted in the country, however, slow it might be. As soon as the insurance agency is informed about the plan, they coordinate the future processes with the hospital and the insured about the process progress status. All the insurance holder needs to do is provide their health care at the hospital during admission for the process to get initiated.

What to do if it is an emergency?

Not all illnesses are planned or arrive after informing an individual. Emergencies or casualties comprise a major fraction of hospital admissions. So, what does one do when they face something unplanned or unforeseen? The kith and kin of the insured can always contact the customer care of the insurance provider and inform them of such a case. The customer care representative can find the nearest cashless facility and recommend it. However, on arrival, it now becomes the prerogative of the hospital to fill up a cashless claim form and submit it to the insurance provider who would have already informed them of the situation. The form is analyzed by the healthcare department, and they revert with the details of the coverage of the health insurance policy to the hospital. All medical bills are taken care of by the insurance company. In case, the claim is rejected or not processed, the hospital and the insured are informed of the rejection reason with proper details. Keeping track of the same and following it up to completion until a settlement is what the insured must ensure after discharge. Hospitals bills have terms and conditions too which need to be taken care off. The sooner you fix the rejection criteria and process the payment to completion; it would be an additional burden which would bother you even after your illnesses are cured. It is always suggested that if you buy an online health insurance plan, keep your close ones informed about the details such as the mediclaim policy number, policy coverage, customer care center dialing number and the likes such that they do not have to look around for financial help instead of looking after you.

2) Claim Through Reimbursement Process

This one is a little tricky for the insured since the process demands that they have to claim it from the service provider after they have been simple words, it means that you pay your bills initially and apply for reimbursement later to get the entire amount back. In such cases, it is not mandatory that the hospital you seek treatment from, be a network hospital. Walk into any hospital that can treat your ailments and keep the bills of payment safe. However, you cannot make use of cashless claim process in this case because it stands null and void.

Provide original bills from the treatment, each one of them, to the insurance company. No insurance company will support or accept your claim without the original bills. Most of the bills are analyzed and verified before it is cleared. Often third-party authorizing vendors are hired to ensure that there are no false claims associated. False claims can refer to fraud bills, manipulated documents, etc. If the claim falters or is found to be incorrect at any stage of verification, the claim is rejected then and there. Therefore, it is recommended that you keep the bills intact such that they are legible and do not fail authorization at any step.

After the claim is verified and found legitimate, the claim is processed easily without any hassles, and the payment is made to the registered bank account of the insured. However, if the payment is rejected due to any condition, the insured is notified of the same through customer advising methods. It could be via email, post or even a call from the claim-processing department.

It is only natural that one might question that if medical bills are enough documentation to claim reimbursement from the healthcare provider. Of course, you need a certain set of documentation in place to make the process a success. Any missing document can put your claim progress on hold. Now you do not want to run pillar to post just because you do not know what document it is! So, we have a consolidated list which you can follow during the claim process. Even it differs across organizations; you can always have a follow-up conversation with the agent you purchased your mediclaim policy from to give you a manual which contains all the details.

The most important documents which are also mandatory are as follows:

  • A duly filled and signed claim form. This is the document which can be downloaded online or obtained from the insurance office.

  • Investigation report

  • All original bills, receipts, memo, etc. Any bill missing will account for your loss.

  • A medical certificate, your case file and other documentation which should be signed by your doctor. It is more like an attested copy of your illness track record while in the hospital.

  • Cash memo for medicines that have been purchased from an external pharmacy.

  • Discharge card, summary report and all clearance documents.

  • If it was a medical emergency such as an accident or a casualty, an FIR should be deposited. If the FIR is unavailable, a Medico-Legal Certificate should be mandatorily provided.

After all, documents are duly verified and processed; the claim is deemed to be completed. The final step is crediting the entire claim amount to the insurer's account which is declared at the time you buy health insurance.

Usually, third-party administrators are responsible for verifying your documents and claims. As incentives are higher to limit claims, they take stringent steps to cancel or reject any claim that comes their way. This is in line with the instructions given by the insurance providers themselves.

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