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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When buying a new health policy, the area of concern for the most is perhaps ‘claim settlement’. While we supposedly refer to the process as complicated but with proper awareness, claim settlement in health insurance can be made smooth and hassle-free.

Why Do You Need a Go Claim Settlement in Health Insurance in India

When buying a new health policy, the area of concern for the most is perhaps ‘claim settlement’. While we supposedly refer to the process as complicated but with proper awareness, claim settlement in health insurance can be made smooth and hassle-free.

Why Do You Need a Good Health Insurance Policy?

Nowadays, with the remarkable increase in the expenses associated with medical procedures and treatments, investing in real health insurance plans has become a necessity. To enjoy the monetary respite and peace of mind, especially in times of need, you have to have a medical insurance cover for you and your loved ones.

What Should You Consider Before Purchasing Health Insurance?

It is quite obvious that you will be doubtful about whether the insurer or the private company would settle your claim or not. To help you understand let us first discuss three important insurance claim ratios:

• Claim Settlement Ratio for Health Insurance: It implies the claim solving capability of the company. The ratio would be high when the majority of the claims are solved. The ratio is calculated as (Number of Claims Settled)/(Number of Claims Reported + Number of Claims Outstanding at the Start of the Year – Number of Claims Outstanding at the End of the Year)
• Claim repudiation ratio: It gives you an idea about the percentage of claims rejected by the health insurance company. It is calculated as (Number of Claims Rejected/Total Number of Claims){ed162fdde9fdc472551df9f31f04601345edf7e4eff6ea93114402690d8fa616}
• Claim pending ratio: It tells you about the claims that are neither approved nor rejected. It is calculated as (Outstanding Claims/Total Claims){ed162fdde9fdc472551df9f31f04601345edf7e4eff6ea93114402690d8fa616}

Meaning of Claim Settlement and How Does the Data Help?

The claim ratio data gives you a clear insight into the history of the insurance company’s claim handling process. Although new insurers would naturally have low ratios, claims data helps you in analysing companies that have been in business for the same period.

If you have already invested in a valuable health insurance policy, you need to be familiar with all the aspects of claim settlement for easy dealings.

Claim Settlement Types

Cashless Claims

In the case of a planned hospitalisation, you can select a cashless settlement. Make sure you follow these steps for a hassle-free process.

• Check whether the health condition is covered according to the terms and conditions of the policy. Also, track a hospital included in the network of the insurer before going ahead with cashless hospitalisation
• Inform the insurance company that you want a cashless claim on your policy. Fill the Pre-Authorisation Form during admission and submit it to the TPA counter
• Submit documents such as the Cashless Card given by your insurance company and some documents for identity at the TPA counter
• The original hospitalisation documents will be kept by the insurer once you receive the cashless approval. Therefore, keep a copy of the documents for your records
• Check the pre-post hospitalisation cover in the health insurance plan. Retain all the medical reports, prescriptions and bills to claim expenses

Reimbursement Claims

Some policies do not offer cashless claim facility. In such cases compensation claims can be made in the following ways:

• You need to inform the insurer by submitting the duly filled claim form offered by the company within 30 days after discharge from the hospital
• Submit all the original medicine bills, hospital bills, and reports duly signed and stamped
• The Discharge Summary issued by the hospital after your discharge has to be given to the company
• The follow-up prescription, showing that you are fit after hospitalisation, has to be given in the original. You need to submit the bills within three to four months after discharge for post-hospitalisation expenses
• For future reference, you must retain copies of all the documents submitted

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The IRDA is the sole governing institute for all insurance bodies in India. An average consumer puts in a lot of effort into assessing the claim settlement ratios of individual insurance companies before they buy their product.

Understanding past claims and track record of settlements of an insurance company is important while shopping for a medical claim insurance. While this may be an essential parameter to judge the institution, it’s certainly not everything. Read on to know more.

Claim Settlement Ratio in Health Insurance

Claim Settlement Ratio in health insurance is the ratio of claims submitted to claims settled in a given time. The proportion of claims filed against the number of claims paid or settled is measured. When all submitted claims are paid, the company can claim 100{ed162fdde9fdc472551df9f31f04601345edf7e4eff6ea93114402690d8fa616} settlement ratio. Subsequently, when there are rejected claims – the ratio is below 100{ed162fdde9fdc472551df9f31f04601345edf7e4eff6ea93114402690d8fa616}.

Why do Health Insurance Claims get rejected?

Health insurance claims are mainly rejected due to the following:

1. Pre-listed conditions within the contract:

To keep the plans viable and make premiums affordable, the insurance provider lists certain conditions like waiting periods, sub-limits and exclusions. Therefore, claims that fall into these categories are exempted. These are approved by IRDA.

2. Fraudulent and misrepresented claims:

Falsified records or undisclosed information if traced, can lead to claim denial. This is usually the case where petitioners sign their forms without thorough study.

Outrageous charges quoted by the treating doctor or the hospital, fraudulent claims by a group of patients, etc. are also not entertained.

An efficient health insurance company that has proper legalities in place is due to see rejections. This proves that claims settled and rejected are both in accordance with the contract, without deviations.

How to Ensure 100{ed162fdde9fdc472551df9f31f04601345edf7e4eff6ea93114402690d8fa616} Claim Settlement

Here are some key parameters to make sure your claim is not rejected:

• Always fill the contract yourself and read the proposal document thoroughly before signing.
• Take the time to analyse terms and conditions of the policies. Use web services and online comparison tools to find your perfect health insurance plan
• Private analyses indicate that about 95{ed162fdde9fdc472551df9f31f04601345edf7e4eff6ea93114402690d8fa616} of health insurance claims are rejected. Ensure that all past and present health conditions are truthful
• Make sure declarations of the dependants like parents and in-laws, spouse and children are updated.
• File claims within the time frame in the contract.
• Provide all the necessary details requested by your insurer. Speak to your broking firm or an agent for clear understanding.

What to do when your Claim is rejected?

The following is the route to take when filing a grievance:

• Go back to the contract and check for inaccuracies and misinterpretation of information.
• Contact TPA to rule out systemic errors or communication problems.
• Check supportive documents submitted for the medical insurance being claimed. Ensure all reports, bills including pharmacy receipts are there.
• Talk to your doctor or hospital about providing adequate proof if your claim is denied for unnecessary medical procedure.
• Register an appeal with the insurance company first, stating all the reasons and with all the proofs.

Insurance Ombudsman

If your insurance company further rejects your claim or if there is no response within 30 days of filing, you can register a complaint with the insurance Ombudsman, who will then follow legalities to test your claim and offer a solution.

Top Five Health Insurances for 2015-16

• Apollo Munich: 89{ed162fdde9fdc472551df9f31f04601345edf7e4eff6ea93114402690d8fa616}
• Religare: 87{ed162fdde9fdc472551df9f31f04601345edf7e4eff6ea93114402690d8fa616}
• Star Health: 79{ed162fdde9fdc472551df9f31f04601345edf7e4eff6ea93114402690d8fa616}
• Max Bupa: 86{ed162fdde9fdc472551df9f31f04601345edf7e4eff6ea93114402690d8fa616}
• Cigna TTK: 94{ed162fdde9fdc472551df9f31f04601345edf7e4eff6ea93114402690d8fa616}

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Claim Settlement Ratio

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IRDA

What to do when your Claim is rejected