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How health insurance claims get paid

Most people buy indemnity cover, commonly known as mediclaim. There are primarily two ways in which an indemnity type health insurance claim gets paid- cashless service at a hospital or reimbursement of expenses. Here's how both of these work.

ET CONTRIBUTORS|
Nov 16, 2019, 10.41 AM IST
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You must collect all the properly stamped and signed original bills from the hospital.
By Davinder Singh

There are two types of health insurance covers: indemnity and defined benefit plans. In an indemnity plan, you can claim reimbursement of actual expenses incurred up to the amount insured for specified illnesses as per the terms and conditions of the policy. In a defined benefit insurance plan, you are insured for pre-agreed specified illnesses.

You will get the sum insured if you contract any of these and provide acceptable proof of the same. Here, payment of sum insured is not linked to any of the expenditures incurred but to the contracting of the disease, subject to terms and conditions of the policy.

Most people buy the indemnity cover, more commonly known as mediclaim. This article explains how insurance is paid out in an indemnity policy.

There are primarily two ways in which an indemnity type health insurance claim gets paid- cashless service at a hospital or reimbursement of expenses.

Cashless service at a hospital
When you buy a health insurance plan, your insurer will provide you with a list of hospitals that are a part of the network. If you were to be treated in any of these hospitals, you can avail of cashless benefits. You can provide your insurance e-card in these affiliated hospitals and continue with hospitalisation without paying any cash. The only other criteria being that the medical condition or illness is covered as a part of your health insurance plan, subject to the amount you are insured for. The hospital sends all the bills to the insurer when the patient is discharged. And upon evaluating the expenses, the insurer settles the bill.

Reimbursement of expenses
The other way to claim your health insurance is via reimbursement. You can pay for the medical expenses upfront and get the treatment done, and later submit all the bills to your insurer. Upon assessment of the bills, the insurer reimburses the expenses that you have incurred based on your sum assured limit. The reimbursement mechanism comes into the picture if the insured is admitted to a non-network or non-affiliated hospital in case of an emergency or otherwise.

When can you file a claim?
Most health insurance policies require the patient to be admitted for a minimum of 24 hours or more to avail the benefits. This is barring a few daycare procedures, which are explicitly mentioned in your policy documents. Checking the validity of your health insurance plan is also important. Ensure that your policy has not lapsed, else you will not be able to make any claims.

Though the wordings of an insurance policy can be a bit tedious to go through, you must be aware of some of the highlights. Policy details such as limits on certain procedures, room rent caps, waiting period for certain diseases, co-pay, exclusions of the policy are important. Health insurance plans usually have waiting periods for certain diseases or illnesses. Your insurer might not honor a claim for a disease or medical condition which is still in its waiting period. If you rely on your employer for a health insurance plan, they provide insurance cards at regular intervals. Carrying the latest iteration of the card is a must, as the older card might no longer be valid.

How to get your claims paid
Almost all the network hospitals have an insurance desk, that you will end up visiting during a hospitalisation. To avail of cashless service, you will have to fill out a pre-approval form at the desk for planned hospitalisation. For emergency hospitalisation, intimation can be done within 24 hours of admission. Only the insured's identity proof along with the health card is needed for admitting a cashless claim. All you need to do is fill the pre-approval forms given by the insurance desk at the hospital and the rest of the documentation would be taken care of by the third-party administrator (TPA) desk of the hospital.

It is recommended that you speak with the hospital regarding your policy coverage details right from the beginning. This will avoid any sort of confusion and the hospital staff will get back to you if the policy coverage runs out.
To ensure that your reimbursement claim goes on smoothly, you must cater to reimbursement-specific factors.
There is a varied array of papers that you must provide for a hassle-free experience. Documents such as duly filled claim form signed by the policyholder, doctor's advice for admission, the complete breakup of the final bill provided by the hospital and original bills and receipt for pre- and post-hospitalisation expenses.

You must collect all the original bills from the hospital, which must be signed and properly stamped. You must also provide all the doctor reports, diagnosis reports, admission reports, etc. along with any other additional investigation and details of tests. A crucial document for a reimbursement claim is the discharge summary. Do not forget to provide it along with your claim. While you must submit the originals, it can be helpful to keep a copy of all the documents with you.

Once your insurer reviews and accepts the claim, they will transfer the amount to the account details provided in the forms. Thus, you must ensure that you have entered the correct details and double-check the same before submitting the forms and also submit a cancelled cheque along with the policyholder's know-your-customer (KYC) documents.
This way, there will be easier claims settlement and lesser chances of any claim rejection.

(The author is Chief Business Officer, SecureNow.in)
(Disclaimer: The opinions expressed in this column are that of the writer. The facts and opinions expressed here do not reflect the views of www.economictimes.com.)

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