At some point in time, most of us have been sceptical when it comes to settling claims in Health Insurance in India, given the premium we spend annually. Doubts about the claiming process, the integrity of the insurance company and so on often bog us down.
Why Do We Need a Health Insurance?
An unfortunate accident or an unexpected medical illness can disrupt the regular course of a peaceful life. While nothing can compensate for the emotional trauma that these can cause, there is a respite for the financial blows at least.
With a good health insurance plan, the individual or group is entitled to the best available medical care in an emergency as well as pre-planned expenses, without stressing about the costs.
Ratios to Be Considered before Shortlisting a Policy
Claim Settlement Ratio
This ratio indicates the successful resolution of claims. Higher the ratio, the better the company.
Claim Repudiation Ratio
This ratio indicates the number of claims rejected by the insurer. The reasons could be that the said treatment is not covered under the plan or fraudulent claims, etc.
Claim Pending Ratio
All the claims that are outstanding fall under this category, such as incomplete data during submission, misinterpretation of events and illness or issues under investigation.
How to Claim the Health Insurance Policy?
One can opt for cashless claims in cases of planned hospitalisation.
- Check whether the medical treatment or illness in question is covered under your policy as per its terms and conditions. Cross check if the chosen hospital has an association with the insurance company before going ahead with the hospitalisation.
- It is always imperative to inform the insurance company whenever you are planning to claim your policy. During admission, you will be required to fill a Pre-Authorisation Form, which has to be submitted at the Third Party Administration counter along with other documents like Cashless Health Card provided by your insurance company and KYC documents for identity reasons. They usually take a copy of these, not the original. The TPA form is submitted to the insurer for approval.
- Once the insurance company approves the cashless claim, insurer retains the original documents relating to hospitalisation. Always make sure you ask for copies of your records.
- Always check which pre and post-hospitalisation expenses are covered by your health plan. Accordingly, save all the required bills, medical reports and prescriptions. These are usually settled on a reimbursement basis. Check the terms and conditions of the timeline related to such claims.
In cases where your policy does not provide cashless claims or, if you opt for a hospital which does not have a tie up with your insurance company, you will need to get your expenses reimbursed.
- Make sure you intimate the company about the claim, fill out the reimbursement claim form and submit it within 30 days from the discharge date
- Attach all the signed and stamped original hospital bills, medical bills and related reports with the reimbursement form. Registration No of the hospital, the name of the patient and date has to be mentioned. These are to be attached with the prognosis of the doctor who suggested hospitalisation. This document acts as proof that your hospitalisation was not voluntary, but your doctor’s advice.
- Submit the discharge card given by the hospital to your insurance company confirming that you are fit to be discharged along with your doctor’s follow-up prescription indicating the status of your fitness
- Post-hospitalisation expenses bills can be submitted within 60, 90 or 120 days from the date of discharge, depending on the terms of your insurance plan
- It is vital for you to retain copies of all the documents submitted for future reference. Your claim should be settled within 2-3 weeks after registration.
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