Owing to the rising medicare costs in recent years, the gap between healthcare costs and its affordability has also proportionately increased. An adequate Health Insurance is hence becoming crucial for bridging this gap. Due to significant rise in lifestyle diseases, health insurance is now seeing a gradual uptake among customers. However, many still remain unaware on availing insurance benefits during a claims scenario. This last minute hustle can easily be resolved if you are well versed with the process and methods of filing health insurance claims.
Most of the indemnity products, pay claim up to the treatment expenses after deducting non-medical charges and other deductions as per policy terms and conditions. The claim will be reimbursed by the insurer known as reimbursement claims or customer can opt for cashless facility at designated hospitals.
Cashless claims:
Usually, the cashless claims facility is provided for medical treatment in one of the network hospitals of your insurer. The insured is not required to shell out any sum for the treatment except for the non-medical items. The insurance company settles the payment directly with the hospital depending on the insurance policy terms and conditions and the sum insured that the customer has opted for. One can avail the benefits of cashless claim facility for both planned medical treatment/surgeries and unplanned medical exigencies.
In order to avail the cashless claims benefit, a customer needs to follow below mentioned procedure:
- In case the hospital admission is planned, customer should approach insurance desk of the hospital which guides them on the cashless facility. The insurance desk forwards entire case with pre-authorization application form to insurer. Basis the case details and policy T&C, insurer approves the cashless facility. Generally, this approval should be taken 4 – 7 days prior to the treatment.
- Once you connect with your insurance company, they will inform you about the documents that may be required. Post sharing these documents and medical details with the insurer through insurance desk, it evaluates the treatment details as per policy terms and conditions and informs the concerned hospital and insured.
- The customer needs to produce following documents at the network hospital in addition to the documents that are specified by the insurer:
- Pre-Authorisation letter (completed by insurance desk)
- ID card issued by the insurance company
- Health Insurance Policy
- Aadhaar Card, Pan card / Form 60 (For KYC purpose)
Reimbursement health insurance claims:
Another process that one can opt for settling a health insurance claim is the reimbursement mode. This situation mostly arises when a patient chooses the hospital as per his choice and convenience and the hospital is not empanelled with the insurer. In such scenarios, a policy holder has to make the payment for all the medical bills that are related to the said treatment and later on file the claim for reimbursement.
A health insurance is a stitch in time. However to ensure that it is a backstitch, it is highly advised to be aware of what your policy offers at the time of purchase itself. A detailed understanding of what’s covered and what’s not helps you to avoid any last minute ordeal.
(The writer is Head-Health Claims, Bajaj Allianz General Insurance)
