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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Claims Settlement Ratio

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