It is an obligation of any health insurance provider to respond to the claims made by the policy holder by receiving, investigating and acting upon the claim made. The invoice is sent to the insurance company either by the policy holder or by the health care provider which includes a doctor, a health care clinic or a hospital, to generate a claims process. The invoice shows in detail the services the policy holder or the insurer has received, and the health insurance provider is then required to review and investigate the invoice and take an action of accepting or rejecting the claim. While it is under the discretion of the health insurance provider to reject a claim in case the policy holder has not listed out pre-existing health conditions, with all the details being accurately furnished by the insured, the health insurance provider is obliged to respond to the claims.
There are two ways in which the insured can claim the health expenses to the insurance provider.
- Cashless Claim Process: To avail the cashless claim facility, the insured individual needs to be treated at a network or empanelled hospital. Generally, most health insurance providers have a tie up with few of the top hospitals and health care clinics of the city- government owned and private as well. The insured needs to provide a physical proof of the health insurance to avail the cashless claim facility. This is usually an e-card given by the health insurance provider to the insured or a document given by the health insurance provider to the policy holder to be produced in the network hospital during the claim. Once the patient is discharged, the invoice of the services received by the insured are provided by the empanelled hospital to the insurance provider. This goes through a series of administrative and customer service levels and the health insurance provider evaluates invoices, the expenses and disburses the payment. This is usually settled in few hours after the discharge of the patient.
Under the circumstances where the insured needs an emergency hospitalisation, the customer service desk of the insurance provider can be contacted to identify the nearest network hospital. In this case, the policy holder can avail cashless hospitalisation by producing the e-card issued by the health insurance provider. The hospital, in this case, fills the claim request form with all relevant documents and sends to the insurance provider via an email or a fax. As an acknowledgement, the insurance provider sends a letter of Authorisation to the hospital informing about the coverage. After evaluating the bills, the health insurance company disburses the payment for the services and hospitalisation expenses directly to the network hospital. In case the claim is rejected, the policy holder is being informed through a letter indicating the reason for rejection of the claim.
In cases where the policy holder has a planned treatment, the insurance provider must be notified in advance- usually 4 days ahead of the planned treatment with information on which of the listed empanelled hospital the insured wishes to be treated. In this situation, the policy holder fills the cashless claim request form and sends to the insurer via an email or post or fax. The letter of Authorisation is issued by the insurer to the hospital regarding the coverage. The insured can avail cashless treatment benefit by displaying the health insurance card. In case the claim is rejected, the insurer informs the policy holder. The claims for the expenses is directly paid to the hospital.
- Reimbursement Claim Process: If the insured is not treated in one of the network hospitals, the cashless facility could not be availed. Rather the insured makes the payment and later claims the expenses from the insurer by producing the following documents:
- Claim form
- Medical Certificate issued by the medical practitioner or the hospital
- Discharge summary
- All bills and invoices
- Prescription and cash memos
- MLC, in case of an accident along with the copy of a FIR
How to Claim in Health Insurance Online
Most of the health insurance providers have the option of claiming the expenses online. One needs to login to the website of the insurer and down the relevant claims request form. The duly form claims request form needs to be submitted by the insured along with other relevant documents needed for the claim. The list of documents which the insured would be required to upload online are the same as one would require for the reimbursement claims process. A letter of authorisation is issued by the insurer and the expenses are paid out if the treatment or ailment is covered in the policy. In case the claim is rejected, a repudiation letter would be sent to the insured.
Reasons to Claim in Health Insurance
With the rising expenses in the health care sector, a health insurance is a must need for every individual. The reasons for a claim to the insurer can be in case of an accident, or an emergency treatment or a planned treatment. With addition of riders, one can claim reimbursement even for critical illnesses.