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How to file health insurance claim the right way

how to claim health insurance the right way moneymonc

The COVID-19 pandemic has affected healthcare in many ways. This has often led to delays in non-urgent surgeries or procedures. However, with the decline in the number of COVID-19 cases, most people have started undergoing the procedures that they had postponed due to the pandemic.

Now if you also have a health insurance policy, either provided by your employer or your own, it is important to understand the steps to register a health insurance claim.

Insurance companies have tie-ups with several leading hospitals so as to provide cashless treatment to the insured. In case the insurance company does not have a tie-up with the hospital, they reimburse the cost of expenses incurred by the insured.

Most health insurance policies in India cover procedures that require at least 24-hours hospitalisation in the country.

We have listed below the two ways to apply for a health insurance claim – cashless and reimbursement. Let’s discuss both in detail:

Cashless Claims – How it’s done

Cashless treatments can only be availed at network hospitals that are listed by your insurance company.

One can check the insurer’s website for the nearest hospital with whom they have a tie-up for a cashless claim.

Hospitals have an insurance desk to address insurance and cashless claim related queries. Ask them for a pre-authorisation form. Or, you can download and get a printout of the document from the TPA’s (Third Party Administrator) website. Cashless processes vary according to the type of treatment provided at the hospital, whether the treatment is planned or unplanned.

Process for planned treatment

You need to inform the insurance provider about the treatment you’re about to undertake at least 4 days before the date of treatment. You will receive a notification from the provider concerning the policy and eligibility.

During hospitalisation, you must display the confirmation letter along with the health insurance card. The hospital gets paid directly by the provider. 

Process for unplanned treatment

Emergencies are unwarranted and require you to reach the hospital as soon as possible to undergo treatment. In such situations, you must provide the health insurance card on arrival at the hospital.

A cashless claim request form will be filed at the hospital to be sent to the insurance provider, who will then issue an authorization letter to the hospital, indicating the extend of coverage. In the event of a rejection, you will get a letter from the company stating the reasons for rejection.

Reimbursement claim – How it’s Done?

If you choose a non-network hospital, one has to pay all the medical bills before submitting a claim for reimbursement.

You have to provide all the necessary documents and bills to the provider for evaluation. So, it’s prudent to keep them all safely in a file.

After evaluation if the insured is eligible for reimbursement, the amount will be transferred to the insured’s registered account.

In case of a rejection, the policyholder is informed of the reasons for rejection.

Documents Required for health insurance claim

*Claim form filled in

*Aadhar card

*Policy Document

*A medical certificate signed by the doctor treating the ailment.

*Discharge summary if present.

*Original receipts

*Bills for medicines got at the hospital chemist

*Completed medical report as recorded by the hospital

 *Medico-Legal Certificate (MCL)or FIR in the event of an accident

Health insurance keeps you funded for future medical needs and emergencies. Read the terms of your health policy carefully before applying and ensure that you follow the correct procedures to file a claim to ensure you have a fast, hassle-free claim settlement process.

(Emad Desai is Mumbai-based independent journalist and Chemical Engineering student, who writes on history, finance and political science)

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