Health Insurance claim

Even if the hospitalization is less than 24 hours, your health insurance is applicable. A daycare procedure that leads to a surgical treatment under a local or a general anaesthesia would require less than 24 hours of hospitalization. But, Out-patient department (OPD) doesn’t count in this category. Few examples of a daycare treatment are dialysis, prostate, eye surgery, piles/fistula, angiography, etc.

Knowing the protocol of registering a claim is very important. There might be emergency situations wherein you get admitted to a non-network hospital. You will be required to pay the hospital and other medical bills and then claim reimbursement from your health insurance company. It is important that you know the documents required to make a reimbursement health insurance claim.

A cashless health insurance can be denied in case the hospitalization takes place in a non-network hospital.

·         First Consultation paper

·         Duly filled and signed claim form

·         Supporting documents for the diagnosis of the critical illness

·         Surgical and past medical history from the attending physician’s report

Yes, you can file health insurance claim of your own.

Service charge, administrative charge, extra bed, syringes, telephone charges, laundry charges, diapers, toiletries, etc. are not covered in a health insurance claim. You should therefore read your policy documents thoroughly to understand the inclusions and exclusions of the policy.

Every health insurance provider offers a cashless treatment in a network hospital. However, it is important that a minimum of 24 hours hospitalization is required to claim your health insurance policy

Generally, there are three types of waiting period that every health insurance policy has:

• Disease specific waiting period: Usually certain diseases are covered by a health insurance policy after completion of 2 years of waiting period. However, this differs from one health insurer to another
• Pre-existing diseases: Every health insurance company covers pre-existing conditions after completion of 3 to 4 years.
• Initial waiting period: You can file a claim only in case of an accident immediately after the purchase of the health insurance policy. Others have a waiting period of 30 days.

On renewal, your health insurance company will charge a claim loading amount whenever you make a claim. Usually, health insurers mention the same in the policy itself

Typically, a health insurance policy covers all types of medical treatment expenses. However, there are exceptions in case of pre-existing health conditions, dental care, eye care, life-style diseases and intentional self-injury, etc.

Yes, if your health insurer offers a facility, you may certainly file a health insurance claim online.

As per IRDAI, a health insurance claim should be processed within 30 days from the date of receipt of the last document. However, if there is a delay from the insurer’s end, then an interest is applicable right from the date of the receipt of the last required document till the date of claim payment at a 2% interest rate above the bank rate. But, the health insurer may also initiate an investigation or a scrutiny before the completion of 30 days from the date of the receipt of the last required document. In this case, your health insurer is mandated to settle the claim within 45 days from the receipt of the last required document. If the delay is beyond 45 days, a 2% interest rate above the bank rate would be payable by the insurer to the policy holder from the date of the receipt of the last required document till the date of claim payment.

Health insurance claim settlement ratio is the ratio of the total number of claims settled by the health insurance company against the total number of claims received in that particular financial year. The higher the claim settlement ratio of a health insurance company, the better are the chances of your claim getting settled. While comparing health insurance online, do not forget to compare the claim settlement ratios of different health insurance companies.

In case you wish to avail a cashless treatment, it is important that you ensure that the said ailment is covered as per your policy terms and conditions. If the said ailment is allowed, take an approval from the TPA to avail the medical treatment. A pre-authorization form needs to be filled in prior to hospitalization. You then need to submit the same at the insurance desk in the hospital. This form will either get approved or rejected based on the policy terms and conditions. The TPA will then send the approval letter to the hospital, post which the treatment can commence.

If there is a medical emergency, you may simply flash the health card at any of the network hospitals to avail the cashless claim benefit. After getting admitted, you may send the pre-authorization form/request to the TPA. Thus, carrying your Health cards every time is essential since emergencies come uninvited. In case you are not able to show your Health card, you may at least show your photo identity proof and the policy number for pre-authorization purposes. You also need to submit the ‘emergency certificate’ along with the pre-authorization form to the TPA mentioning that the nature of admission was an emergency.