Health Insurance Claims Process: Cashless & Reimbursement Claims

With the increasing risk of diseases and the costs of healthcare services heading upwards, many people are looking to protect themselves with a health insurance plan . For the policy-holder, the ultimate payback is when the claim is accepted.

• Check if the particular illness for which the insured individual is admitted for treatment is covered by the hospital.
• If yes, then the individual can exercise the option of cashless treatment (subject to terms and conditions of the policy) after producing all requisite policy-related documents (e-card, any other physical copy).
• Once the patient is discharged, the insurance company shall foot the bill after verifying the same.
• In case the claim gets rejected, the insurance company shall intimae the policyholder in writing, along with reasons for rejection.

• The insurance provider must be alerted at least 4 days in advance in advance, before the commencement of the treatment.
• A duly filled cashless claim request form must be submitted to the insurance provider.
• The insurance company shall review the request and the policy and intimate the person of the policy cover and eligibility to raise a claim.

1. Planned Treatment - Planned hospitalization is when a person has enough time to deliberate and select a hospital before getting admitted. Here, one must bear the following details in mind:
2. Unplanned Treatment - Unplanned hospitalization arises in the event of an unforeseen emergency. In such a situation, the policyholder can touch base with the insurance company through its customer care department to know more about the network of empaneled hospitals.A duly filled cashless claim request form must be submitted to the insurance provider. The insurance provider shall in turn issue an authorization letter to the hospital indicating the policy coverage.

1. Cashless Claim Process In a cashless policy, the insurance company directly settles the bill with the healthcare institution, that is empanelled itself with the insurance company.
2. These are the general guidelines in a cashless health insurance policy . However, the claims process depends on the type of treatment- whether it was planned or unplanned.
3. Reimbursement Claim Process If the policyholder opts or is compelled to get treated in a hospital that isn’t empaneled with the insurance provider, then he or she shall have to go through the reimbursement route. The reimbursement claim process is slightly different.Here, the policyholder shall have to bear the cost of medical and hospitalization expenses at first and then raise a claim. He or she shall be required to submit all the required documentation in lieu thereof. The insurance company would then evaluate and scrutinize the claim on every aspect to assess its credibility.If the claim and all supporting information are found to be authentic, then the claim shall be accepted and the amount covered shall be reimbursed to the policyholder. the insurance company shall intimate the policyholder in writing and state the reasons for rejection.

Following is a general checklist of documents required to trigger a health insurance plan:

• Primary document - Duly filled claim form
• Supporting documents - Medical certificate or form attested by the doctor on duty, the Investigation Report, discharge summary or discharge card issued by the hospital
• Bills - All original bills and receipts, prescriptions and cash memos issued by pharmacies or the hospital
• Others - In case of an accident, even the FIR or the Medico-Legal Certificate shall be required

In Conclusion Many people get overwhelmed at the time of raising a claim. They find the process complicated and difficult to comprehend. Therefore, it is important to understand the claim process to ensure a seamless and hassle-free experience.

The information contained herein is generic in nature and is meant for educational purposes only. Nothing here is to be construed as an investment or financial or taxation advice nor to be considered as an invitation or solicitation or advertisement for any financial product. Readers are advised to exercise discretion and should seek independent professional advice prior to making any investment decision in relation to any financial product. Aditya Birla Capital Group is not liable for any decision arising out of the use of this information.