Claiming in a Health Insurance Plan

In health insurance, a claim is a detailed invoice that your health care provider sends to your health insurance plan provider. The invoice should indicate all the health care services you received as well as their respective charges. After your health care provider submits the invoice to your health insurance provider, the claim should be processed as per your health insurance plan. 

If you are required to pay part of the medical bill, your insurance provider will forward a summary known as the explanation of benefits that shows what the insurer will pay and what you are required to pay.

Step by Step Process of Making a Claim

There are two types of claims under health insurance plan online; cashless claims and reimbursement claims.

1. Step by step process of making cashless claims

Step 1: Checking

Start by checking whether an ailment is covered as per your health insurance plan terms and conditions. Also, check whether the hospital is within your insurance provider’s network. It is advisable to call your insurance provider for confirmation before hospitalisation.

Step 2: Informing the provider

The next step is to intimate the insurance provider that you wish to make a claim. During admission at the hospital, you may be asked to fill a pre-authorisation form that should be submitted at the Third Party Administration (TPA) counter. The form is then sent to your insurance provider who in turn will authorise the cashless claim.

Step 3: Submission of the relevant documents

While at the TPA counter, you are expected to submit relevant insurance documents like a cashless health card that your insurance provider gives you. You may also be asked to provide KYC documents for identification.

Step 4: Recordkeeping

Once your cashless claim is approved and received from your insurance provider, the insurer retains all the original documents. The documents are retained for insurance plan claims spending and record keeping. You will be required to request for a record of the same from the hospital.

Step 5: Pre-post hospitalisation

Based on your pre and post hospitalisation clause in your health policy, you may be required to retain bills and prescriptions in order to file claims later on.

2. Step by step process of making a reimbursement claim

Reimbursement claims may be filed when you seek treatment in a non-network hospital or when your health insurance plan fails to provide the cashless claim option. Despite the scenario, the following steps must be followed when filing a reimbursement claim.

Step 1: Informing the provider

Start by informing your health insurance provider of the impending claim and submit a duly filled reimbursement claim form within 30 days after the discharge from the hospital.

Step 2: Submission of the relevant documents

Attach original copies of the medical bills, medical reports, and hospital bills. The bills and reports must be signed and stamped with the claim form. The bill should indicate the hospital name and registration number while the reports must mention the patient’s name, date of admission and discharge as well as the prescriptions.

Step 3: Submitting the discharge summary

Your hospital discharge summary must be submitted to your health insurance plan provider. It indicates the treatment you received and whether you were fit for being discharged from the hospital.

Step 4: Submitting a follow-up summary

A follow-up prescription or summary from your doctor indicating your health status and fitness after a hospitalisation must be submitted with the reimbursement claim form. Depending on your health insurance provider, the follow-up prescription and summary can be submitted 60, 90, or 120 days after discharge.

Step 5: Record Keeping

Ensure that you retain copies of all the submitted claim documents like medical bills, reports, and follow-up prescription for future reference. Reimbursement claims are settled 2 to 3 weeks after they are registered.

Advantages of having a Health Insurance Plan

1. Be prepared for emergencies

Health care is becoming expensive. Therefore, with a proper health insurance plan, you are guaranteed to receive the best health care in the event of an accident or an unexpected illness. Recovery can be hindered by your ability to pay for the best health care services. Health insurance is designed to ensure that you are always prepared to deal with emergency health care needs.

2. Have access to preventative care benefits

Most people suffer from serious diseases like cancer due to not having it detected at an earlier stage. With a good health insurance plan, you are allowed to visit the hospital occasionally for check-ups. This way, serious diseases are treated in time before they worsen. Regular medical check-ups can be quite expensive without health insurance.

3. Have Access to resources

Health insurance plans offer a wide range of benefits and resources to individuals. For instance, some health insurance providers offer 24 hours nurse hotlines while others offer 24/7 ambulance services. Go through a summary of resources offered by different health insurance providers on to ensure that you make informed decisions.

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