At some point in time, most of us have been sceptical when it comes to settling claims in Health Insurance in India, given the premium we spend annually. Doubts about the claiming process, the integrity of the insurance company and so on often bog us down.

Why Do We Need a Health Insurance?

An unfortunate accident or an unexpected medical illness can disrupt the regular course of a peaceful life. While nothing can compensate for the emotional trauma that these can cause, there is a respite for the financial blows at least.

With a good health insurance plan, the individual or group is entitled to the best available medical care in an emergency as well as pre-planned expenses, without stressing about the costs.

Ratios to Be Considered before Shortlisting a Policy

Claim Settlement Ratio

This ratio indicates the successful resolution of claims. Higher the ratio, the better the company.

Claim Repudiation Ratio

This ratio indicates the number of claims rejected by the insurer. The reasons could be that the said treatment is not covered under the plan or fraudulent claims, etc.

Claim Pending Ratio

All the claims that are outstanding fall under this category, such as incomplete data during submission, misinterpretation of events and illness or issues under investigation.

How to Claim the Health Insurance Policy?

Cashless Claims

One can opt for cashless claims in cases of planned hospitalisation.

• Check whether the medical treatment or illness in question is covered under your policy as per its terms and conditions. Cross check if the chosen hospital has an association with the insurance company before going ahead with the hospitalisation.

• It is always imperative to inform the insurance company whenever you are planning to claim your policy. During admission, you will be required to fill a Pre-Authorisation Form, which has to be submitted at the Third Party Administration counter along with other documents like Cashless Health Card provided by your insurance company and KYC documents for identity reasons. They usually take a copy of these, not the original. The TPA form is submitted to the insurer for approval.
• Once the insurance company approves the cashless claim, insurer retains the original documents relating to hospitalisation. Always make sure you ask for copies of your records.
• Always check which pre and post-hospitalisation expenses are covered by your health plan. Accordingly, save all the required bills, medical reports and prescriptions. These are usually settled on a reimbursement basis. Check the terms and conditions of the timeline related to such claims.

Reimbursement Claims

In cases where your policy does not provide cashless claims or, if you opt for a hospital which does not have a tie up with your insurance company, you will need to get your expenses reimbursed.

• Make sure you intimate the company about the claim, fill out the reimbursement claim form and submit it within 30 days from the discharge date
• Attach all the signed and stamped original hospital bills, medical bills and related reports with the reimbursement form. Registration No of the hospital, the name of the patient and date has to be mentioned. These are to be attached with the prognosis of the doctor who suggested hospitalisation. This document acts as proof that your hospitalisation was not voluntary, but your doctor’s advice.
• Submit the discharge card given by the hospital to your insurance company confirming that you are fit to be discharged along with your doctor’s follow-up prescription indicating the status of your fitness
• Post-hospitalisation expenses bills can be submitted within 60, 90 or 120 days from the date of discharge, depending on the terms of your insurance plan
• It is vital for you to retain copies of all the documents submitted for future reference. Your claim should be settled within 2-3 weeks after registration.

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To have a health insurance has become quite important these days. It protects you by providing financial security in times of need. You save money through comprehensive health plans during medical emergencies.

What Is A Health Insurance Claim?

A health insurance claim is a formal request for payment made by the insured individual to an insurance company. The company reviews the claim for its validity, and then payment is made as per the terms to the insured.

A third party acting on behalf of the insured by the approval of the insurance company can carry out transactions as well.

Insurance claims cover a lot of things, from death benefits on life insurance policies to routine health check-ups by your local doctor. Many a times, claims are filed by third parties on behalf of the insured person, but generally, only the person listed on the policy is entitled to claims payment.

Processes To Claim Health Insurance

There are different procedures for a health insurance claim that are based on the type of claim you make with your insurance provider.

• Cashless facility: The insurance provider takes care of the medical treatment costs in their network hospitals. The insured must carry the cashless card provided at the time of policy purchase along with valid ID proof during admission and claim process. The insurer provides an electronic pre-authorisation form before hospitalisation.
• Reimbursement: In this case, the customers pay hospitalisation fees and later get reimbursed from the insurance company. Reimbursement is done after proper documents are submitted to the company.

Reimbursement can be made for single or multiple insurers. If everything is in order, your health insurance claim gets approved in 30-40 days.

The important point is that if your documentation is in order and all the requirements have been taken care of, no insurance company can deny your health insurance claims.

Claims Settlement in Health Insurance

There is always a doubt in customer’s mind about whether the insurance company will settle the claim or not. One must understand about Claims Settlement Ratio to get a clearer view.

Claim Settlement ratio tells about the claim solving ability of the insurer. A higher claim settlement ratio means that majority of claims are getting resolved. For example, if an insurer has 60{ed162fdde9fdc472551df9f31f04601345edf7e4eff6ea93114402690d8fa616} claim settlement ratio, it means that he/she settles 60 out of 100 claims.

The companies mostly accept health insurance claims. That is because the insurers service a network hospitals where a cashless facility is available.

In the case of non-network hospitals, insurance claims are accepted as long as the treatment lies within coverage and stipulated requirements have been fulfilled. It must be fairly clear that no insurer rejects a legitimate insurance claim.

Steps Involved In Claim Settlement

The process is carried out in three stages – claim reporting, claim processing and claim settlement.

In claim reporting, claims can be reported online, at company offices and branches through a special helpline, or through SMS and e-mail.

In claim processing, your claim details are carefully scrutinised. The company assesses your claim and raises a requirement within a week or so. It also informs you of any pending documents.

The final step is claim settlement. Once the claim request is approved, and all the documents have been received, the claims are settled, provided no investigation is required. Moreover, to reduce hassle, electronic modes of transfer are used to pay your claim.

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