Health Insurance Claims Process—Explained

Health insurance policies are primarily about securing financial coverage towards medical aid for yourself and your family. It is a smart and prudent way to prepare for unforeseen medical events. Health insurance not only protects your finances but more importantly, gives you access to quality healthcare when you need it the most. However, despite a range of benefits offered, people find the health insurance claim-process tiresome, giving the entire policy bad press.

The method of getting the cost of the medical services that you have availed, covered, constitutes the health insurance claim process. A few guidelines can explain to you how to claim health insurance money when the need arises.

There are two types of claim settlements: Cashless & Reimbursement

Let us understand how they differ from each other-

The cashless claim settlement allows you to get admitted to a network hospital where you don’t need to pay directly from your pocket. The insurer pays the hospitalization and other expenses directly to the hospital. On the other hand, under the reimbursement process, you have to pay for all your medical bills and hospitalization costs from your pocket, and later have to claim the expenses from your insurer.

Generally cashless claims need to be intimidated to the insurance company before the date of admission. However that is only possible for planne medical situations. In case of emergency treatment, you can contact the customer care help desk to learn about the network hospitals. This list is also uploaded on the website. The cashless claim process can be initiated by showing your health insurance card. The hospital also contacts the insurer, fills the claim request form and confirms the status of your claim. In such cases, the letter of rejection or acceptance of the claim is issued by the insurer.

Reimbursement claims come into the picture when the hospital you are at is not a network hospital, or if the claim has been denied. In this case you need to ask for a copy of all the original documents from the hospital, because these same documents need to be submitted to the insurance company for their assessment. Post the assessment of the claim, the money will be transferred to your account.

In essence, the major difference between the two is that in case of a cashless claim, your savings and liquidity remains unaffected.

STEPS FOR CASHLESS HEALTH INSURANCE CLAIMS

Below are steps you need to follow to claim for cashless health insurance:

1. Contact the Insurer through Toll-Free Healthline

Contact the insurance provider three days in advance so that the health-relationship manager can help you with the process. In case of emergency, contact the insurer within 24 hours of hospitalization.

2. Confirm Your Identity at the Network Hospital

You will need to show your health insurance card to the hospital authorities, issued by the insurer. The network hospital will then be able to contact the insurer using the details given on the card, such as your policy number, card number, your name, age etc.

3. Cashless Hospitalization Claim Request Form

The claim request form needs to be filled up. The form required details like medical history of the patient, line of treatment, and estimated costs are mentioned. The hospital will help you with these details.

4. Insurer Contacts the Network Hospital

On analyzing the information received from the hospital, the insurer issues the authorization letter concerning the claim. In case of insufficient documents, the insurer asks the hospital for the same, and on a satisfactory receipt, the authorization letter is issued.

5. Claim Service Associates

On request from your end, the insurer can provide you with a claim service associate to navigate through the paperwork and other documents.

6. Final Request for Authorization

Once the treatment is completed, the hospital sends a final request for authorization with the final hospital bill and the discharge summary. The discharge will be given only on final approval from the insurer.

7. Payment to the Network Hospital

The network hospital needs to submit original documents to the insurer based on which the payment is made, assessing the claim.

8. Pre-Post Hospitalization Payouts

If you have chosen a comprehensive health insurance policy, pre and post hospitalization expenses with medical bills need to be submitted from your end to claim the amount you have spent from your pocket.

STEPS FOR REIMBURSEMENT HEALTH INSURANCE CLAIMS

Below are steps you need to follow to claim for reimbursement under your health insurance:

1. Contact the Insurer through Toll-Free Healthline

Like cashless treatment, here also you need to contact the insurance provider three days before the hospitalization so that the health-relationship manager can help you with the process. In case of emergency, contact the insurer within 24 hours of admission.

2. Hospitalization

Avail your treatment in the hospital and settle all the bills from your end. The costs levied during the period of admission can be claimed along with pre and post-hospitalization expenses. Collect all the necessary documents such as case papers, hospital bills, discharge summary, investigation reports, pharmacy bills etc.

3. Submit Your Claim

The duly filled claim form needs to be submitted along with the list of documents mentioned above. A copy of the form is included in the policy kit you receive at the inception of the term, or you can download it from the insurer’s website. Submit the claim form and all the documents to the corporate office of the insurer, or the nearest office. This needs to be done within 15 days from discharge.

4. Claim Assessment

By analyzing the information provided by you, the insurer accepts the request and processes the claim. In case of insufficient information or a lack of documents, the insurer asks you to provide the same. Failing to provide necessary documents within the given period may lead to claim rejection.

5. Claim Service Associate

On request from your end, the insurer can provide you with a claim service associate to navigate through the paperwork and other documents.

6. Claim Settlement

On approval of the claim from the insurer, you will receive the claimed amount to your bank account via NEFT or through DD/Cheque.

Conclusion

Do not get intimidated by the financial jargon in the insurance policy. By scrutinizing every line, one can easily claim and settle their dues with the insurer. Making health insurance claims has become more accessible; all you need to do is- read the steps carefully and take action accordingly.

In this way, you can easily file a claim under your health insurance plan. Buy ManipalCigna ProHealth Plan and easily get your claims processed.