Health insurance is an important investment in protecting your health and finances. It covers a variety of medical expenses, from hospitalization to surgery and even medication. However, it is important to know how to claim health insurance to reap the benefits of your policy. In this blog, we will discuss the types of health insurance claims, the documents required to claim health insurance, and how the health insurance claim process works.
Types of Health Insurance Claims:
There are two types of health insurance claims - cashless and reimbursement claims.
Cashless Claims:
In cashless claims, the policyholder has to get treatment from a network hospital that has a tie-up with the insurance company. The policyholder can inform the insurance company about the planned hospitalization, and the insurance company will provide a pre-authorization letter to the hospital. This letter mentions the approved amount for the treatment. After the treatment is completed, the hospital sends the bills directly to the insurance company for payment. The policyholder does not have to pay anything, except for non-medical expenses like food or telephone charges. Policyholders can get reimbursement for pre and post-hospitalization expenses by submitting actual bills to the insurance company.
Reimbursement Claims:
Reimbursement claims are applicable when the policyholder gets treated at a non-network hospital or if the policyholder cannot get cashless treatment due to certain reasons. In this case, the policyholder has to pay for the treatment upfront and then claim reimbursement from the insurance company later. The policyholder has to submit all the required documents to the insurance company within a specified time period. Once the documents are verified, the insurance company reimburses the approved amount to the policyholder.
Documents Required to Claim Health Insurance:
The documents required for health insurance claims vary depending on the type of claim. However, there are some common documents that are required for both cashless and reimbursement claims. These include:
- Claim form: This is a form that needs to be filled out by the policyholder while making the claim. It contains details about the policyholder, the treatment received, and the medical bills.
- Original bills and receipts: Original medical bills and receipts need to be submitted as proof of the medical expenses incurred. These bills should contain the name and address of the hospital, the date of admission and discharge, and a detailed breakup of the expenses incurred.
- Discharge summary: A discharge summary is a document provided by the hospital after the patient is discharged. It contains details about the treatment received, the duration of hospitalization, and the diagnosis.
- Doctor's prescription: The doctor's prescription for the treatment received needs to be submitted.
- Investigation reports: If any diagnostic tests like X-rays or blood tests were done, the reports need to be submitted as proof of the tests and the expenses incurred.
- KYC documents: Know Your Customer (KYC) documents like an Aadhaar card, PAN card, passport, or voter ID must be submitted for verification purposes.
- Pre-authorization letter (for cashless claims): A pre-authorization letter is required for cashless claims. This letter is provided by the insurance company and needs to be submitted to the hospital before the treatment.
Steps Involved in Health Insurance Claim Process
Step 1 - Intimation
The first step in the health insurance claim process is to inform the insurance company about the hospitalization. If it's a planned hospitalization, then the policyholder should inform the insurer in advance. In case of an emergency, the policyholder should inform the insurer within 24 hours of hospitalization.
Step 2 - Filing the Claim
Once the policyholder has informed the insurer, the next step is to file the claim. The policyholder can either opt for a cashless claim or reimbursement claim, depending on the circumstances.
For a cashless claim, the policyholder needs to fill in the pre-authorization form provided by the insurer. This form needs to be submitted to the hospital's insurance desk, which will verify the policy details and send it to the insurer. Once the insurer approves the claim, the hospital will provide cashless treatment to the policyholder.
For a reimbursement claim, the policyholder needs to submit the claim form along with the necessary documents to the insurance company. The claim form is available on the insurer's website or can be obtained from their office. The policyholder needs to ensure that the form is filled out correctly and all the necessary documents are attached to it.
Step 3 - Documentation
The documentation process is an essential part of the health insurance claim process. The policyholder needs to submit the following documents along with the claim form:
- Original hospital bills
- Discharge summary
- Investigation reports
- Prescriptions and receipts for medicines
- Any other relevant documentation as required by the insurer
Step 4 - Claim Settlement
Once the insurer receives the claim form and necessary documents, they will verify the details and approve the claim. In case of a cashless claim, the insurer will settle the medical bills directly with the hospital. In a reimbursement claim, the insurer will verify the expenses incurred and reimburse the policyholder for the same.
Conclusion
The health insurance claim process can be a little complex, but it's essential to understand it to avail of the benefits provided by the policy. The policyholder needs to ensure that all the necessary documents are submitted to the insurer to ensure a smooth and hassle-free claim settlement process.
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