How to Claim Health Insurance

Insurance policies are not easy to understand and the difficulty magnifies even further when you are faced with a medical contingency and you have to file a health insurance claim. Whether your policy is cashless or reimbursement you don’t want a rejection due to missing documents, inadequate information or discrepancies in the claim form. To help you sail through the claim process and to ensure that you get the maximum payout, it is very important to understand how the entire claim process works.

There are two ways to claim health insurance
  1. Cashless
  2. Reimbursement

What is a Cashless Claim?

A cashless claim is when the policyholder does not have to pay the hospital bill out of his own pocket for any medical treatment taken or surgery performed at a network hospital. The entire bill is cleared directly by the insurance company in accordance with the terms and conditions of the policy. A cashless claim can be filed for both emergency medical contingencies and planned hospitalisation.

The policyholder needs to follow these 4 steps for claiming cashless health insurance:

  1. Pre-authorisation
    Pre-authorization is a process done by the insurance company to verify the policy holder’s eligibility to claim for the medical procedure. The pre-authorisation process is initiated when the policyholder presents the health insurance policy card and a government approved identity card to the hospital.

    After the eligibility of the card has been verified and the need for hospitalisation has been established, the line of treatment is revealed and the cashless process starts. For preliminary approval, the insured also needs to submit the patient’s admission notes, investigation reports, and consultation papers. All of this is required to establish trust between the insurance company and the policyholder.

  2. Enhancement During Admission
    At times, after the pre-authorisation request has been sent to the insurance company, the hospital realizes that the estimated expense for the medical treatment mentioned in pre-authorisation request can increase. In this case, the hospital sends the new expected figure and this is known as an enhancement during admission.

  3. Queries in Cashless Admission
    If the insurance company finds any discrepancy during admission, it will raise a query to the hospital which ideally needs to be resolved within 24 hours. Once the hospital sends a reply, the claim is reassessed on the basis of policy terms.

    This may require the hospital to submit additional material facts to support the query resolution. At this stage, if the hospital is unable to resolve the query then the pre-authorisation stands rejected and the insured is instructed to file the medical claim via reimbursement. This is because the insurance company wants to check the documents and verify the admissibility of the claim.

  4. Cashless Discharge
    When the insurance company has accurately established all the data points, the need for hospitalisation is justified, the financial parameters are in line with the policy, and the hospital has submitted all the original documents, the insurance company will then settle the payment directly with the hospital according to the policy terms.

Things to Keep in Mind for Cashless Medical Claims

  1. Check your eligibility
    Avoid claim rejection by checking your eligibility before you file a claim! Consult SureClaim to know if your treatment is covered, what the co-pay is, and know if there are any deductibles or exclusions. Be prepared in advance and avoid costly mistakes.

  2. Documents to carry for cashless
    Have you gathered all the documents required to file a claim? Are they in the right order? A single discrepancy or a missing document can get your claim rejected. Consult a SureClaim expert and make no mistakes!

  3. Pre-authorisation denial
    If the insurance company finds any discrepancies in the medical documents during the pre-authorisation and is unable to get the required data points, then the insurance company denies the pre-authorisation. Then the insured has to pay for the treatment at the time of discharge. However, the claim can be filed via reimbursement process.

  4. Cashless denial
    Whether your claim has been denied due to miscommunication or a missing document, consult a SureClaim expert and get clarity. A SureClaim expert will review your documents and suggest a suitable plan of action so you can claim via reimbursement smoothly and get maximum payout.

  5. Deduction in cashless
    You have filed a claim of Rs 20,000 which was your hospital bill at the time of discharge. But, your insurance company approved only Rs. 8000. Did you check all the deductions in your policy? Did you receive the maximum payout on your bill? Get the settlement reviewed by a SureClaim expert to know that your settlement is fair.

How to Recover Deduction in a Cashless Claim?

Deductions are applied due to co-pay, proportionate, sub-limits, exclusions, and non-medical expenses. The insured can claim every medical expense except the cost of non-medical items from the policy. And, if the sum insured is exhausted on the first policy, then the rest can be claimed from the second or third policy.

What is the Reimbursement Claim?

The reimbursement claim can be filed when the insured opts for treatment at a non-empanelled hospital. Since the cashless facility is not available at a non-network hospital, the insured has to pay for the hospitalisation and medical treatments out of his own pocket and then claim reimbursement. Since a reimbursement claim is filed after the discharge process, the insured needs to provide all the required medical documents in original to the insurance company. The company will then assess the documents against the policy terms and make the payment to the insured.

Which Scenarios are Applicable for Reimbursement Claims?

The insured can raise a reimbursement claim in the following situations:

  • When the patient is admitted to a non-network hospital
  • When the insured opts-out of cashless at a network hospital
  • When the cashless benefit is rejected
  • To raise a claim for pre and post hospitalisation including emergency charges
  • For hospitalisation expenses like blood bank, radiology investigation, etc, for which the payment is made outside the hospital
  • For claiming the deduction in the second or third health insurance policy
  • For claiming Hospi-cash and health check-up benefits

The Steps Involved in a Reimbursement Claim

  1. Claim Intimation
    The insured needs to intimate the insurance company even if he/she is going to file a reimbursement claim after discharge. If the hospitalisation is pre-planned then the policyholder needs to inform the insurance company at least 3 to 4 days in advance and in case of an emergency at least within 24 hours of admission. You can send the intimation via email, call them, visit their website or call their executive.

  2. Collecting Documents in the Right Order
    The policyholder must collect all the original medical documents and itemized bills and submit them to the insurance company in the order mentioned in the insurance policy. These documents include -

    • Copy of Gov. Id Proof with Insurance card
    • Original Hospital Discharge Summary
    • Original Itemized Bills
    • Hospital Bill & Breakup
    • Original Investigation Reports
    • Original Pharmacy Bills
    • Original Prescriptions
    • Copy of FIR/Medico-Legal Certificate (only in case of accidental injury)
    • Original Cancelled Cheque

  3. Getting the Documents Reviewed by an Expert Agency like SureClaim
    The insured must make sure that all the documents are collected and arranged in the right order by having a SureClaim expert verify them. This is because, unlike the cashless process, the reimbursement process starts after the treatment has been completed. So the insurance company suspects an element of moral hazard and oversees every minute detail.

  4. Filling the Claim Form
    The policyholder has the option to fill the reimbursement claim form online or by hand or they can take the advice of a SureClaim expert and make sure there are no errors in the claim.

  5. Claim Submission
    The reimbursement claim must include all the required documents. So if you have any confusion before filing a reimbursement claim, consulting a SureClaim expert will ensure that you have complete guidance at every step and you get the maximum payout faster.

  6. Claim Tracking and Query
    A reimbursement claim can be tracked online from the website of the insurance company or by giving a call to the insurance company’s TPA on their toll-free number. And, if a query is raised by the insurance company while the claim is being assessed then the policy holder needs to resolve the query in a timely manner.

  7. Query Resolution Advice by an Expert Agency like SureClaim
    The policyholder can consult a claim expert for any assistance or advice on resolving a query that the insurance company has raised. SureClaim has assisted more than 35k users and helped them maximize their claim amount. A SureClaim expert will do all the legwork for you and improve the chances of maximizing your claim by 45%.

  8. Claim Approval and Settlement
    Once all the documents are verified according to the terms of the policy and the queries are resolved in a timely manner, the insurance company approves the reimbursement claim and pays the policyholder.

Things to Keep in Mind for Reimbursement Claims

  1. Check your eligibility
    It is very important to check if you are eligible to file a claim if you don’t want a rejection in the end. The insured needs to verify if:
    • The policy is active
    • The policy covers the diagnosis, procedure or medical treatment taken
    • There are any limitations or exclusions in the policy
    Confirming the coverage facilities will save you a lot of stress and surprises. Or you consult a SureClaim expert to know your choices as per your eligibility and saving big on your out of pocket expenses while avoiding delays and rejections.

  2. Documents to collect from the hospital
    Do not forget to collect all the medical documents, test reports, consultations and bills from the hospital at the discharge as you will need to submit all these documents in original to your insurance service provider when you claim reimbursement.

    But before you submit your claim form, make sure you have your documents verified by a SureClaim expert to ensure you are not missing out on any piece of information or document as it can delay your claim process or result in a rejection.

  3. Timely claim and query submission
    If the insurance company raises a query, they will give you 3 reminders to resolve the query. If you fail to resolve the query in a timely manner, your reimbursement claim can be rejected.

  4. Reimbursement denial
    You can contest a reimbursement denial and still get the maximum payout with SureClaim’s expert guidance. To know the reasons that can lead to reimbursement denial, visit this post.

  5. Deduction in reimbursement claim
    Deductions are applied to cap the liability of the insurance company on the claim amount. This means that the policyholder has to share the cost from the bill and pay the hospital for the deductibles mentioned in the policy contract. But calculating the deductibles by referring to the policy documents is a tricky process.

    We have the expertise and experience to handle your hassles and ensure that you are completely aware of the deductions and don’t get any surprises at the last minute.

And when your claim is settled, have it reviewed by a SureClaim expert so you know you’ve received the maximum possible payout.