Health Insurance Claims Procedure:-
There are two methods of payment of claims.
(1). Cashless option: when the treatment is taken from the network hospital and necessary approvals have been obtained. This option is easy to opt in case of planned surgeries or immediately on admission into the Hospital necessary procedures are completed by the Insured to obtain pre authorization and obtain the sanction from the Insurance provider/TPA.
(2). Reimbursement of Claims: If the Insured takes the treatment at hospital of his choice which may not a Network Hospital or if he opts to take the treatment even in Network hospital but he has neither taken the pre-approval from the Insurance provider/TPA either due to any emergency or due to any other reason. Hence as there is absence of pre-authorization and as the Insurance provider has not granted the CASHLESS limit, the Policy holder is requested to firstly makes all the payment to the hospital where the treatment is taken and subsequently submit all the necessary medical papers and prescriptions, investigation reports, bills/proof of payment and receipts to the TPA or the Insurance Company and get the reimbursement as per the terms and condition of the Policy.
Following general procedure need to be undertaken by the Policy holder in order to Claim under the Health Policy.
· Please contact the Insurance Help Desk at the hospital
· It is advisable that separate claim intimation is sent to the TPA/Insurance provider to register the claim under the health Policy.
· Show the copy of the Policy and ID card of the insured (provided by the health insurance provider), for the purpose of necessary identification by the Hospital.
· The hospital will verify the identity of the insured and will submit the pre-authorization form to the Health insurance provider / TPA of the policy holder.
· The insurance provider/TPA will review all the submitted documents and process the claim according to the terms and conditions of the health insurance policy and communicate the amount for the cashless settlement. If this is not done then initially the insured need to pay for the charges which will be subsequently reimbursed by the TPA/Insurance provider as per the terms and condition of the Policy.
· Some of the health insurance providers also assign a field doctor to make the hospitalization process easier and faster for the insured.
1. In case of Cashless Treatment:
o Procedure to File a Claim (Planned / Emergency Hospitalization):
Network hospitals will provide the cashless facility to individuals who have selected ‘claim processing by TPA’. The insured individual can undergo treatment in network hospitals provided that the TPA (Third Party Administrator) has given the authorization in advance.
The list of network hospitals can be accessed at the official website of the Insurance provider. The same website can be accessed to download the request from which should be filled in with the requisite details and submitted to the TPA so that it can approve and authorize the same.
o Claims Process:
When the TPA receives the request form along with other related medical details from the network provider or the insured individual, it will provide the network hospital with the pre-authorization letter once it has verified the information received. At the time of discharge from the hospital, the insured individual will have to sign the discharge documents following verification and he / she will also have to bear inadmissible and non-medical expenses. If the insured individual cannot provide the necessary medical information, the TPA holds the right to decline pre-authorization. If the pre-authorization is declined due to any reason then, the insured individual can undergo treatment based on the advice of the treating doctor after which he / she will have to furnish the relevant claim documents to the TPA so that claims can be reimbursed.
2. In case of Reimbursement of Treatment Expenses:
o Procedure to File a Claim:
To have claims reimbursed, the insured individual will have to furnish the relevant claim documents to the TPA within the time limit prescribed in the policy. The insured individual can undergo treatment based on the advice of the treating doctor. The insured individual will have to bear all costs incurred for the treatment. The insured individual will also have to furnish the bills along with the other relevant documents to the company / TPA for the reimbursement of claims.
o Documents Required:
The documents that must be furnished when claiming reimbursement from the company / TPA include the original claim form disclosing all the necessary details, payment receipts, original bills, hospital discharge certificate, original hospital cash memo, prescription from the chemist, investigation test reports along with the attending doctor / medical practitioner’s prescription, original payment receipt, certificate related to diagnosis and bill receipts from the attending doctor / medical practitioner, certificate from surgeon disclosing the plan or nature of operation underwent by the individual along with the diagnosis certificate supported by bills, and any other document as required by the TPA or the company.
o Claims Process:
Should the company accept the insured individual’s settlement offer; the customer will receive the payment after the offer has been accepted.
In case the company rejects the claim of an insured individual for any reason whatsoever, it will communicate the same to the individual in writing within 30 days after it has received the final document.