Be Aware of how to approach your health insurance claims

Most probably, you can get stuck in health insurance claims process when you or your loved ones are hospitalised due to illnesses.

Our intent here is to give an account of high-level requirements during the process of health insurance claims for your benefit, in order that you get the fundamental understanding of how to approach the claims process.

Cashless Claims

There are three major follow ups in cashless claims,

1. Choose a Network Hospital – Cashless claims are possible only in hospitals that are in the Network list of your health Insurer
2. Approach the hospital’s Insurance Desk – All hospitals have an Insurance Processing Desk
3. Discharge Procedure at the Hospital – Coordinate for early completion of discharge formalities.

Choose a Network Hospital

Find out your best choice of hospital, which falls in the network list of your health insurance company. Normally, people seek the recommendation of the physician who diagnosed them of the ailment and referred to a hospital where the physician may know the specialist.

Whatever the case may be, check and choose a hospital that falls in the network list of you health insurer.

Approach the Hospital’s Insurance Desk

Once you identify the hospital, after registration formalities and initial tests, diagnosis and consultations, before admission you have to approach the Insurance Desk. You may also be mostly prompted by the hospital staff to approach the insurance desk after they understand that you hold a health insurance policy.

At the insurance desk, you need to produce the patient’s health card issued by the insurer/third party administrator (TPA) and extend the basic details along with the patient’s file with estimation of treatment charges.

On receipt of all the details, the insurance desk will send out a request to the insurer or TPA for pre-authorization approval.

The insurer or TPA is supposed to get back with any queries within 30 minutes or if everything is ok are supposed to approve the pre-authorization within 45 minutes on an average.

There could be delays,

• From the insurance desk in sending the pre-auth request.
• From the TPA/Insurer in sending the initial queries/approval
• From the insurance desk in answering queries

In few cases, the hospital insurance desk can also decline your cashless request due to various reasons despite having an arrangement with your health insurer.

In all such cases, there will be a necessity for an expert claims coordinator from your side to ensure all these processes are efficiently coordinated and followed up for early resolution. If you have bought your health insurance from a committed insurance broker, their claim support officer will ensure this efficient coordination in getting the pre-auth approval and claim settlement at the earliest.

Discharge Procedure at the Hospital

During the hospitalization, it is better that you have necessary touch with the insurance desk/billing and have a track of billing, for your own benefit of information, which will help you understand the portion of payment related to non-medical expenses that you need to pay. During the pre-auth approval, the insurance desk will also give you an estimate of probable amount that you may have to pay from your pocket.

Patient Discharge at the hospital will mostly be initiated in the afternoon on the planned day and can get delayed beyond evening. It is better to follow up the insurance desk and billing appropriately to ensure documentation is completed for discharge earlier. Here too, your insurance brokers’ claim support officer will be helpful in early coordination from insurer/TPA for approval of bills enabling completion of discharge formalities.

In the absence of a follow up, the discharge formalities are likely to be delayed.

Reimbursement Claims

In case, if your choice of hospital does not fall in to the network list of your health insurer, you have to opt for a reimbursement procedure.

In reimbursement claims procedure, you will have to pay the hospitalisation expenditure out of your own pocket and submit the bills and relevant reports after the discharge of the patient from the hospital.

Here, you carry the whole risk of hospitalisation expenses until the reimbursement is processed and approved by the Insurer.

Again, there are three important aspects to reimbursement claims,

1. Check the admissibility of the claim before hospitalisation
2. Collect all relevant documents before discharge from hospital
3. Submission of completed claim papers to Insurer

Check the admissibility of claim for the hospitalisation

First and foremost in reimbursement claims is, you have to check with your Insurer or Insurance Broker for the admissibility of claim for the hospitalisation that you are planning. You may not know whether the ailment that you are planning for treatment is covered or excluded. So, it is important that you check this before admission for treatment at the hospital. Else, after the hospitalisation is over, the Insurer may decline the claim, citing exclusion as per terms of insurance policy.

Collect all the required documents from the Hospital before discharge

Take utmost care in collecting and saving all the relevant documents related to the hospitalisation. The following are the list of very important documents required for settlement of reimbursement claims.

1. Discharge Summary in original
2. Cash Payment Receipt in original
3. Hospital Bill with break up of treatment charges
4. Diagnosis/Test/Investigation Reports
5. Doctor’s Prescriptions
6. Pharmacy Bills
7. Claim Form filled, sealed and signed by Hospital authorities

Submission of claim papers to Insurer

After discharge, you can seek the support of your TPA or Insurance Broker to submit the above papers along with the following for getting the claim amount reimbursed.

1. Claim form duly signed in original
2. Government Issued ID Proof copy
3. Additional KYC forms as per requirement of the Insurer
4. Bank details/Cheque leaf copy for reimbursement credit.

On submission of the above documents to the Insurer, subject to no further queries, applicable reimbursement amount will be credited to your bank account within an average period of 15 working days.