Claim process for your health insurance policy!

Health insurance provides you protection against expensive treatments. It helps you pay the full cost of medical services when you’re injured or sick. It not only relieves you from financial distress but also gives you confidence to fight those odds in life. With your medical insurance, you can afford the medication cost in your desired hospital and need not compromise on the quality of treatment.

To make the insurance claim experience hassle free, insurance companies are providing world class services to their customers. This includes handling claims processing professionally and compassionately. Although your insurance company sells an insurance plan to you, when you apply for your insurance claim, it is either processed by their in-house team or is outsourced to a “Third Party Administrator (TPA)”. TPA is the organisation or institution authorised by the IRDA and engaged by the insurance company for a fee. It provides policy and claims services to the insured person for an insurable event.

Process for availing Cashless Claim (for planned hospitalization):

There are times when you plan your hospitalization in advance, especially when you know about the occurrence of an event like maternity, surgery etc. In those situations, you might prefer treatment in a hospital of your choice where you can also avail cashless facility through your health insurance plan. Follow the below mentioned process for a hassle free health insurance claim during planned hospitalization:

Step 1: Approach Network Hospital of your choice for Cashless Treatment

Step 2: Contact the Hospital counter that deals in insurance requests, at least 3-4 days prior to the date of hospitalization. Produce your medical insurance policy card to identify yourself as the beneficiary for cashless service.

Step 3: The hospital, after verifying customer details, sends request to insurance company or TPA. Coordinate with network hospital to forward pre-authorization request (by fax) to insurance provider/Third Party Administrator (TPA).

Step 4: Insurance company/TPA reviews your request and authorizes cashless claim services as per the policy benefits and its terms & conditions.

Step 5: TPA sends the response to the hospital. Your claim request may be approved or denied depending on your policy T&C. The time taken for processing and approving cashless claims varies from 1 hour to 1 day (depending on the insurance provider).

Step 6: (i) If your claim is approved, get admitted to hospital without any deposits and avail cashless services as per your plan. On discharge, verify the hospital bills for accuracy. Any amount over pre-authorized limit has to be paid by you at the time of discharge.

(ii) If your claim is rejected due do some reason, proceed with the usual hospitalization process as a cash patient i.e. pay all your bills and later apply for a reimbursement claim with your insurance provider.

Cashless Claim Process for unplanned/emergency hospitalization:

An individual cannot always plan for his hospitalization in advance. There can be situation when you need life-saving emergency treatment immediately, for instance, in case of accident, unexpected illness etc. For those unexpected moments, keep your family members informed about your insurance details and follow the procedure below for a hassle free claim process:

Step 1: Get admitted to the hospital for emergency treatment

Step 2: Patient or his family members should approach the hospital counter with patient’s health insurance details (Health Insurance Card). This should ideally be done within 24 hours of getting admitted to the hospital. Family members can also contact the insurance provider or TPA directly for sharing health insurance details, in case of lack of assistance from the hospital.

Step 3: Patient’s family members need to co-ordinate with hospital and TPA for arranging the pre-authorization request.

Step 4: TPA will process the request as per policy terms and conditions within defined time period (varies from 1 hour to 1 day).

Step 5: If the request is approved, proceed with cashless services at the hospital else family members need to settle the bills at the time of discharge.

Step 6: If claims were rejected, then proceed with the usual hospitalization process as a cash patient i.e. pay all your bills and later apply for reimbursement claim with your insurance provider.