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In this article, we will delve into the reimbursement claim process at MD India. We assume that if you are reading this article, you are a beneficiary with MD India and you are looking forward to filing a reimbursement claim with MD India.
MD India Reimbursement Claim Process
So what exactly is a reimbursement claim?
When you make the payment for treatment first and then later you submit the bills to the insurer for making the payment for your bills, that is called as reimbursement claim. Your claim should qualify on the following parameters:
- The treatment is covered in the policy. Conversely, the treatment for the disease should not be excluded from the policy.
- In certain diseases, there is a waiting period during which you can’t claim, so you should be claiming for such diseases/treatments after the waiting period is over.
- There was a clear need for hospitalization and the patient was not admitted just for the sake of carrying out tests.
- Lastly, the patient stayed in the hospital for at least 24 hours. Of course, this doesn’t hold true in case of day care procedures.
Now if your claim ticks all these boxes, you are in a good spot to claim. Let’s look at what are the essential ingredients of a health insurance reimbursement claim in MD India.
- You need treatment-related documents such as discharge summary, hospital main bill, bill and package breakup, payment receipts as proof of bill settlement, all the lab and diagnostic reports and implant sticker(s) if any implant was used during the surgery. In the case of reimbursements claims for injuries during accidents, police FIR and hospital’s MLC (medico-legal certificate) are required too.
- You need the right claim form. MD India uses the IRDA-approved claim form.
- You need to fill in the information correctly in the claim form
- Lastly, you must submit the claim within a certain time period after discharge from hospital for your claim to be valid.
Let’s get started. First, you need the claim form.
Download MD India TPA Claim form
As I mentioned above, the IRDA Claim form is required in your reimbursement claim. It has two parts – Part A and Part B claim forms. Part A has to be filled by the claimant and Part B has to be filled by the hospital where treatment took place.
Note that if you are just claiming for pre and post hospitalization expenses, you only need to use Part A form and Part B is not required.
How to Fill MD India TPA Reimbursement Claim Form Part A
Part A is a detailed form and you can consider it as a summary of the whole journey from disease diagnosis till treatment. The information is captured in seven sections, each pertaining to a specific area. Let’s delve into the specifics and try and fill the form. We start with the first section.
Frankly, this one should not have been the first section because it beats the logical flow from a claimant point-of-view. However, we’ll try to crack the thought-process of this form.
MD India wants to know at the very beginning the details of the insurance policy from which you want to claim. So you have to mention the policy number (in case of individual retail policyholders) or the MD India customer ID number in the TPA ID field. If you have both these numbers, preferably put the MD India customer ID or you can enter both. If your policy doesn’t have a policy number, rather a certificate number, then fill in at the requisite field. Make sure that you are claiming in policy for the current year and not using policy number of previous years’ policies.
Give the name of the primary insured/policyholder. This is the person who is a proposer in the policy, or the one who pays the annual premium. In the case of corporate policies, the employee is considered the primary insured.
There are fields for add, phone number, and email ID as well. Fill in the details to which you would like MD India to contact you.
If the patient has any other policy apart from the MD India policy, mention details of that policy in section B. If a patient has 3 or more health insurance policies, just pick one and enter the details. It really doesn’t add any value to your claim.
This is where we talk about the patient. I am assuming you have checked that the patient is covered in this insurance policy to which you are submitting your reimbursement claim.
Give the patient’s name, age, gender, occupation and their relationship with the primary insured/policyholder.
Now it’s time for details related to disease/health issue and its treatment. Provide the name of the hospital where treatment was taken and the room category occupied by the patient. The reason for hospitalization is split into 3 buckets – Either it’s a case of delivery, or a case of accident/injury or everything else is an illness. So if a patient underwent surgery due to an accident, pick ‘injury’ as a reason for hospitalization. You need to then provide dates for admission and discharge. Enter the date of delivery or accident in the field – ‘d’. Date of the disease first detected means when was the patient diagnosed with the particular ailment. So if you remember the date of consultation with a doctor who first time told the patient that they’re suffering from the problem, that is your date of disease detection. This helps the insurer to determine how long the patient has been suffering from the current ailment.
There are some more fields related to questions about the nature of the injury. If it was a road accident, tick the middle field. If the injury happened when the patient was under the influence of alcohol or drugs, tick the third box. If the patient fell or slipped on their own, or in extreme cases, if the patient tried to commit suicide, tick the first box ‘self-harm’.
If it is a police case then provide the FIR copy along with your claim. In case of the hospital also issued a medico-legal certificate (MLC) which they generally give in the emergency, attach that in the claim.
Get all the bills you want to claim from MD India and list them chronologically, i.e. list them in the order you got them. All expenses before the date and time of admission are pre-hospitalization expenses, whereas all your bills after the discharge from hospital are posted hospitalization expenses. If you have purchased medicines from a pharmacy outside the hospital while the patient was admitted, that will be counted towards hospitalization. Similarly, expenses towards blood bank charges (if the hospital doesn’t have its own blood bank) will also be covered under hospitalization.
Mention the total of hospitalization and pre and post expenses in the requisite field.
The list that you created in the previous step, now is the time to put that into use. In section F this list has to be entered in the form. If the number of bills happens to be more than 10, use a separate sheet to mention the bills.
On the right-hand side of this table, the total of bills has to be entered. But this time there are 4 categories. Pharmacy bills is a new field. Remove pharmacy bills from hospitalization, pre and post total and put all that against pharmacy bills field.
Lastly, share your bank details in which you want MD India to credit approved claim amount in this section. The bank details must be of the primary insured/policyholder. Most people make mistake here by entering the patient’s bank details while a different person is the primary insured. BTW there are many policies where the primary insured is the proposer in the policy but not a member in the policy, i.e. this person is not covered in the policy but paid the first premium.
Interestingly I had a client today’s whose mother’s claim we are preparing. The policy has many mistakes which he came to know only today. His mother is the only person covered in the policy and her relationship with proposer is mentioned as ‘spouse’. But my client’s name is mentioned as proposer, so technically, the relationship should have been a mother, but wrong data entry has led to this error in the policy. Anyways, since my client’s name is showing as proposer, then in his mother’s claim, bank details should be of his.
Bank account holder’s exact name as per bank records should be mentioned in ‘Cheque / DD payable details’ field. If the claim amount is of more than one lakh, then the PAN number of the primary insured should be mentioned.
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