You have an insurance policy to pay for your medical treatment whether it is planned or unplanned. So, when you are faced with a medical emergency, the first thing that comes to your mind is filing a claim to recover the cost of your medical expenses.
But, after you submit the claim form and the required documents to your health insurance company, you cannot sit back and assume that the process will be taken care of by the insurance company and you will get the payout on time.
Your proactive participation is equally necessary even after claim submission as there are several possibilities in the claim process.
- What if your claim reaches the wrong address due to a manual error?
- What if it is not redirected to the right address and you are unaware of it?
- What if the insurance company has raised a query?
- What if the claim is received but your claim ID is not generated?
To avoid delays and hassles, SureClaim recommends that you track your claim at least once every week. Since the claim process does not follow a hard and fast sequence, your involvement becomes extremely crucial.
Having said that, let’s look into the possible status of your claim which can be classified into any of one of the following 5 categories depending on your unique situation:
- In Progress
When you submit the claim documents and the insurance company receives it and acknowledges the delivery of your claim, your claim ID is generated. Then the insurance company starts working on your claim and this is when your claim is considered to be in progress. However, this ‘in progress’ period can take as less as 2 to 3 days or it might also take a few months; it varies from company to company.
While the claim is in progress, it is reviewed by the insurance company/TPA and if the insurance company finds any deficiency in the claim, then it raises a query which needs to be resolved by the claimant within the given timeframe.
The reasons for which the insurance company can raise a query can be classified into 6 different categories:
- Delay in Sending Claim Documents
When there is a delay in sending claim documents, the insurance company raises a query to know the reason for delay.
If the insured does not send intimation to the insurance company even after the patient is discharged and directly files a claim for reimbursement, then the insurance company wants to know the reason for non-intimation.
- Delayed Intimation
When the intimation is sent late whether due to personal reasons or due to unforeseen circumstances, the insurance company wants to know the reason for delay. So the claimant needs to justify the reason for delayed intimation.
- When the Case is Doubtful
- If the paperwork is arousing suspicion then the insurance company may ask for more information. For instance, if the patient has met with an accident or had an accidental fall in the bathroom, the insurance company would want to dig deeper into the facts. In certain cases, the insurance company may also ask for the FIR, patient’s narration of the incident and the doctor’s statement that the patient was not under the influence of alcohol at the time of the incident.
- If the proof of services rendered is not consistent then the insurance company can raise a query asking for the medical bills, doctor’s prescriptions, OT notes and other relevant documents in original.
- If the information provided is inconsistent, for instance, the name of the patient is not the same in the ID card or the bank details provided, there is a discrepancy in the date of admission and discharge, or if the bill total does not tally, a query can be raised.
- Inadequate or Missing Information
- If the claimant has filed a claim for kidney stone or a knee replacement surgery where the condition has not manifested overnight, the insurance company can raise a query and ask for more information. The insurance company might ask for first consultation papers and investigation reports to ensure that it is not a case of non-disclosure.
- If the claim form is not filled completely then the insurance company can raise a query for the deficiency.
- If the discharge summary is not complete and the complete breakup of the bill is not given.
- If any relevant documents are missing. For instance, the bill for a specific report is attached but the report is missing or an implant sticker is missing in the case of a knee replacement surgery.
- To Get the Complete Picture
- If the insurance company wants more information about the continuity of an active policy which has been managed by different TPAs over the years. This is done to check the waiting period, disclosure of pre-existing diseases, etc.
- Delay in Sending Claim Documents
If your policy has lapsed because you failed to renew the policy before it expires, then your claim will get rejected. Also, if you have filed a claim for a medical treatment that is not covered in the policy or the waiting period is still applicable on the treatment for which you have filed a claim, then also your claim can get rejected by the insurance company. So, it is very important to check your eligibility before filing a medical claim.
Whether your claim has been rejected or you are not satisfied with your claim returns, consult SureClaim and have all your queries resolved by an experienced claim expert.
- No Status
No status is when you have sent the claim documents but you are unable to track the claim status. This can happen due to any of the following reasons:
- The policy is Not Valid
When your policy has lapsed and you file a claim for a policy that is not active, the claim will not be considered valid and hence there is no status.
- The TPA has Changed
You have an active insurance policy but the TPA has been changed and you are not aware because the new card is not issued to you. Now if you send the claim documents to the previous TPA then your claim will not be processed. You need to request the previous TPA to send you your original documents back. You should then send the original documents to the current service provider. Meanwhile you cannot track your claim status.
- The Insurance Company/TPA Wants to Receive the Claim Documents at a Specific Office
Many a times, the insurance company or the TPA needs you to send the claim documents to a specific office address. So if you have sent the claim documents elsewhere, you need to send an escalation mail/letter. This should include the courier ID and insurance ID stating, kindly send it back or send the claim documents to the address specified by the insurance company or the TPA.
- When the Documents Don’t Reach the Insurance Company
This happens either because the person to whom you have handed over the claim documents has not sent it to the insurance company or when the claim documents have been sent to the wrong address. So it is important to check with your agent or the staff at the insurance company’s office to make sure that it has been sent to the right address specified by the insurance company.
- When the Insurance Company has Received the Claim but not Registered
For this you need to track the courier using the tracking code so you can take action immediately. If you cannot see the status within 10 days of sending the claim documents, then you should check back with the concerned person.
- The policy is Not Valid
If all the queries are resolved by the calimant in a timely manner, all the required documents are submitted, and the claim is in accordance with the terms of the policy, then the insurance company approves the claim.
However, it is very important to check if you have received the maximum possible payout against your claim. Consult a SureClaim expert and have your documents reviewed to make sure that you have recovered the complete cost of the treatment and hospitalisation.
Lack of information regarding the claim process can prove to be very expensive. Read the Ultimate Guide to Medical Claims to know the scenarios in which health insurance claims can be made.
If your expectations are not met by the insurance company or if there is any delay in the claim process, then you should raise your grievance with the insurance company to know the reason for delay or deductions. This is where a SureClaim expert can help you get the maximum payout without any stress or hassles!