Owning a health insurance policy can be beneficial during times of medical emergencies. You have to file a claim with your insurer at times like these, and your insurer will process and settle the claim so that the financial payment is made for the medical treatment you receive. However, if you compare health insurance policies, you will find that this process of filing a claim differs from one insurance company to another.
Moreover, claims are of two types – reimbursement claims and cashless claims. In reimbursement, the insured makes the payment for the treatment and the insurance company later reimburses the insured. The process of a cashless claim involves the insurer making the payment to the network hospital without involving the insured. Read on to learn more about the process of reimbursement claims in detail.
Health Insurance Claim Reimbursement Process
Before you learn how to file for reimbursement, it is important to know that a reimbursement claim is applicable in a scenario when the insurer can not provide a cashless treatment facility.
Inform Your Insurer
The first step in health insurance claim reimbursement is that after you have purchased the health insurance online you should contact your insurer as soon as you are hospitalised.
If your medical insurance policy includes family members and one of them is admitted to a hospital of your choice, it will be easier for you to inform your insurance company about the hospitalisation.
Pay Your Bills and Gather All Documents
The next step in the health insurance reimbursement process is paying the medical bills. You must ensure that the details and dates on the bills are accurate before you sign the bills. Any discrepancy found at this stage will potentially affect your entire claim process.
Once the bills are paid, you have to keep the invoices and bills safe, along with other original documents related to the hospital.
Follow Up on Documents That are Not Collected
While many tend to overlook this step in the healthcare reimbursement process, it is possible that you will not have all the documents available readily and may have to return to the respective institutions after some days to gather those documents.
Submit All Documents
Once you are discharged and have made the payments from your end, your next step in the medical claim reimbursement process is to submit all relevant documents to the TPA or the insurer according to the insurer’s instructions. Additionally, you have to fill out the claim form accurately so that your claim is not rejected because of a mistake you made.
Wait for the Processing of the Payment
The final step in the reimbursement process in health insurance is for your insurer to verify the claim and the relevant documents you have provided. In case more documents are needed to process the claim, the insurance company will inform you so that you can collect the required documents and submit them to the insurer for the processing of your claim.
If everything goes well, your insurer will reimburse your claimed amount within a specific number of days. Most reputed insurers like TATA AIG generally settle claims within 21 days.
Documents Required for Mediclaim Reimbursement Process
- A Claim Form accurately filled out and signed
- A Medical Certificate with your doctor’s signature
- Your Policy Copy or Insurance Card
- Reports, such as X-ray reports
- Investigation Report, if any
- Hospital discharge card
- Original bills from the pharmacy
- Other original receipts and bills
- MLC/FIR copy (in case of an accident)
- CKYC Form (duly filled), in case the claimed amount is more than ₹1 Lakh
- NEFT details for reimbursing the claimed amount
Common Reasons for Health Policy Claims to Be Rejected
- If the policyholder misrepresents or suppresses a relevant medical fact.
- If the treatment for the medical event/illness is not covered under the health policy.
- If the treatment and its subsequent claim are fraudulent or unnecessary.
Apart from these reasons, there are several other reasons why your claim can be rejected, which is why you should read your health policy carefully, including its exclusions and limitations.
Conclusion
You must know your health policy thoroughly, including how to file a claim, as it can prove beneficial during medical emergencies. Also, if your family members are covered under a health plan, ensure they too know how the claim process works