Health Insurance Claim
Health insurance claim is like an application that a policy owner submits to the insurance company requesting to avail benefits offered under their health insurance policy.
The aim of procuring a health insurance plan is to avail benefits of healthcare services when required. But to gain timely and smooth settlement of medical costs, the first step is to initiate the process of claim settlement. Thus, unless you proceed with the insurance claim process, you will not gain the benefit of the policy.
To avail this facility, there are two ways to go about - you can request a cashless claim by undergoing treatment in a network hospital or a reimbursement claim. Hence, either the medical insurance claim can be submitted to the insurer for compensation or you can request them to pay directly to the hospital.
Below are details regarding the claim settlement process.
Types of Health Insurance Claim
Claim settlement can be initiated in two different ways. They are:
In cashless claim settlement, the hospital bills are settled by the insurer directly if you undergo treatment in one of the network hospitals on the insurer. So, the key feature of this claim process is that the insured has to choose one of the network hospitals of the insurer to get the treatment done.
On the other hand, in insurance reimbursement claims the policy owners have to bear the expenses of the hospitalization costs on their own and they can later request the insurance company to reimburse the expenses. However, in this case you can get the treatment done at any hospital (network or non-network) and get the payment reimbursed later from the insurer.
Health Insurance Claim Process
For Cashless Claims
Below are the steps involved in the procedure of availing cashless claims for a health insurance policy:
- The first step is to get in touch with the help desk of the insurance company at the network hospital.
- You have to show the ID of the insured to ensure that the claim is genuine.
- Once the identification process is done, the insurance help desk at the hospital will verify it through the hospital authority and will initiate the form of pre-authorization to the insurance company for further verification.
- In the next step the insurer will review the documents to initiate the process of claim as per the terms of the health policy of the insured.
- Some insurers even allocate a field doctor for the insured to carry the process easily at the hospital.
- Once the formalities of the claim process are completed, the cashless claim is settled at the hospital as per the policy terms and conditions.
Further, the cashless health insurance claim procedure is divided into two. One is when the hospitalization is planned and the other is in the case of emergency hospitalization.
Steps to follow when hospitalization is planned:
- contact the customer care number (toll-free) of the insurer.
- submit the duly filled pre-authorization form to the insurer via fax. The form should be properly filled by the hospital where the insured is undergoing treatment.
- Once the insurer receives the form, they take the process further to pay for the cashless treatment.
Steps to follow when hospitalization is planned:
- inform the insurance company within 24 hours of emergency hospitalization.
- here again, the insurer or his/her acquaintance must submit the duly filled pre-authorization form (filled by the hospital) to the insurer via fax within 24hours of getting hospitalized.
- the insurer will take the process further to make the payment for the cashless treatment. If the claim is rejected, they will inform the insurer.
In case of health insurance reimbursement claims , the policyholders can get the treatment done at any of the hospitals of their choice. It can be a network hospital or a hospital that is not under the panel of hospitals of the insurer. Here, the insured pays the hospital bills on his/her own and later claims for reimbursement.
The procedure of availing a reimbursement claim for a health insurance policy are as follows:
- the details cited on medical bills need to be verified first.
- so the insured person is required to submit the applicable documents to the insurer with the claim request once the insured is discharged.
- The insurer or the third-party administrator assigned by the insurer will then go through the documents and review them. Once the papers are reviewed, the payment process is initiated, which takes about 21 days to reach your bank account.
- The insurer notifies you if there is a query or any issue regarding the claim or if it is rejected.
Factors Influencing Health Insurance Claim Settlement Ratio
Claim settlement calculations - To calculate the Claim Settlement Ratio of health insurance companies you can use a simple formula. Here, the Claim Settlement Ratio is equal to the total claims settled by the insurer divided by total claims received by the insurer together with the outstanding claims from the starting of the year.
So, while buying a health insurance plan, the insured should check for insurance companies offering impressive claim settlement ratios.
Consistency - Another factor influencing claim settlement ratio is consistency. An insurer offering a consistent medical claim ratio in the last five years should be your choice while buying a health plan. So, you can consider an insurance company offering a high claim ratio or at least a consistent claim ratio to buy your health plan.
Claims received by Insurer - Another influencing factor to consider is to see the number of claims that an insurance company has received during a financial year.
Annual IBA report - Insurance Brokers Association of India or IBAI every year circulates the Claim Settlement Ratio of all insurance companies in India (both public and private). You can check this report in the IBAI portal to check the best companies with medical claim insurance ratio before buying a health plan.
Claim ratio is calculated for all company products - Generally claim settlement ratio is calculated for all the products offered by a company and not just for health insurance products. Thus, the claim settlement ratio is provided for all products and not for a single product. Thus, it is important to consider this point while purchasing policies and checking claim settlement ratios.
Documents Required to Claim Health Insurance
Below are the documents that the insured person needs to submit to the insurance company at the time of initiating the medical insurance claim procedure - (for both cashless and reimbursement claims):
- Health card (provided by the insurer)
- A claim form duly filled by the insurer
- A medical form duly signed by the doctor who is treating the insured.
- The original copy of the complete discharge summary received from the hospital.
- Original copies of all receipts and bills from the hospital.
- Prescription of medicine as well as the cash memos received from chemists or the hospital.
- A copy of the investigation report.
- In case of an accident, a copy of FIR/MLC or Medico Legal Certificate is also needed.
Frequently Asked Question
Claim ratio is equal to the total number of claims settled by an insurer divided by the total number of claims received by the insurer during a policy year.
A claim can get rejected under few circumstances, such as:
- If the insured person claims for an ailment during the waiting period which is not covered under the policy during waiting time.
- Moreover, it also gets rejected if the disease is not covered or permanently excluded from the policy.
- If the insured makes a fraudulent claim.
If your claim is non-fraudulent and you have submitted all the documents properly, then your claim will be paid by the insurer. Make sure to buy a claim from a trusted brand after checking all the required points including claim settlement ratio.
Claim ratio actually depends on the kind of claims received by the insurer during a year as well as their claim settlement procedure. Some companies are more customer centric than others. Insurance companies such as Max Bupa, Iffco Tokio, Apollo Munich and Care health (earlier known as Religare) are very customer focused and good at settling claims.
Both inclusions and exclusion of a policy can be seen and read in the policy document itself. In case of doubt, the insured can speak with the customer care of the insurance provider to gain more knowledge or can read exclusive policy brochures. PayBima team can also help you in this regard to understand various policy details and their inclusions and exclusions. Just contact our customer care support for more information.
Paybima offers 100% Claims support to our customers. The support team at Paybima helps customers with the claim process in India. You can just make a call at our customer hotline to avail support.