Most people find the idea of paperwork scary. It conjures up images of a long fruitless time spent in creating a paper trail. Often, this image scares us off the idea of filing health insurance claims. But filing a claim against your health plan has become much easier. Insurers are simplifying the process to make life easier for their customers. Here’s what you need to know about how to claim against a health policy:
Information you need
Your doctor may advise a day-care procedure or hospitalisation. Let the insurance company know immediately. For a planned hospitalisation, let them know four days ahead of time. You need to keep a few details handy when you contact the insurance company.
Policy number: This is the most vital information. You will find it both in the policy papers and in the health card the insurance company issues.
Contact details: This includes name and address, phone number, alternative number, etc.
Name of the patient: Make sure that this is correctly recorded. If need be, keep an official ID handy. For family floater plans or policies where the patient is an add-on, keep an eye out for mistakes.
Relationship of the insured with the patient: Your policy may cover dependent children, spouse, parents, or in-laws. Make sure you state the relationship clearly.
Name of the hospital: Cashless policies require admission into network hospitals. If you have a cashless policy, make sure you state the correct name of the hospital. For reimbursement policies, there are no network hospitals. But even then, you must state the full and correct official name for all paperwork. So, check the details.
Nature of illness: Ask the physician what you should write. Or, you could ask the admitting doctor in times of emergency hospitalisation.
Date the symptoms started: Ask the patient and the physician. If in doubt, consult your insurance company. Ask what to count as symptoms for the nature of illness specified.
Steps to file a Health insurance claim
If you have a cashless policy, here’s what you need to do:
- Get admitted in a hospital . Your policy document will have a list of hospitals where you can get admitted.
- Show your health insurance card at the TPA (third-party administrator) helpdesk of hospital
- Fill the relevant forms, requesting for the cashless facility
- Submit the form, along with a photocopy of the health insurance card and a valid photo identity proof
- Keep in touch with the TPA desk to know if you need to furnish further details
- Verify and sign bills
- Ask the TPA desk about original discharge summary and other investigation reports
- Keep a copy of all documents for your own records
What happens if your cashless claim is not approved?
You can claim for reimbursement even after discharge. Usually, if there is admission to a non-network hospital, there may be a problem. Also, insufficient information may jeopardise a claim. So, here’s what you do:
- Let your insurance company know within 24 hours of admission
- Talk to your TPA or insurance company about further information they need
- Communicate with your doctor. Your medical advice and documents cover all information
- The medical advice should reflect the nature of illness and need for hospitalisation
- Furnish a copy of all medical advice, test reports, admission advice. Include everything from prescriptions to discharge summary
- File a reimbursement claim or appeal within 30 days of discharge
For reimbursement policies
- Get admitted into the hospital, either within or outside the network
- Inform your health insurance provider immediately
- Settle hospital bills
- Collect all the original bills, documents, and reports at the time of discharge
- File the claim form, attach all necessary documents
- Send the claim form with documents to the TPA or health insurance provider
What happens if your reimbursement claim is not approved?
- Talk to your TPA or insurance company about what went wrong. Was it insufficient information? Did they think there was no ground for hospitalisation? Was the illness not covered by the policy?
- When there is scope for correction, communicate with your doctor. Explain the situation. Make sure so that your medical advice and documents cover all eventualities. Make them state the nature of illness and reason for hospitalisation explicitly.
- Furnish a copy of all medical advice, prescriptions, and test reports. Include admission advice and discharge summary.
- File an appeal within 30 days of discharge.
Make sure you communicate with the insurance company. The Insurance Regulatory and Development Authority of India has certain policies in place. The TPA cannot reject claims. Only the insurance companies may do so. But they cannot do it without sufficient medical grounds. For delayed claims, you can get interest on the amount.
Stay updated with your paperwork, and you’ll find that claiming your health insurance is no big deal at all.