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Health & Fitness

Health Insurance Claim Process and Requirements in India

A life insurance petition is a form made to the Insurance Commission from a health insurance policyholder to access the benefits provided from their health insurance policy. A health insurance policyholder can either get reimbursed or can opt for a direct claim settlement option (also known as cashless treatment) for the availed medical services. Therefore one may either apply the application form or order cashless facilities from the health insurance insurer.

Types of Health Insurance Claim

There are two types of Health Insurance
Image Credit: WLRN

The true value of a health insurance program is offering healthcare coverage as appropriate. In insure that any medical bills are paid quickly and conveniently, the method of applying for health benefits will be begun. A health care contract may be stated in two ways:

CASHLESS CLAIMS

In this type of health insurance reform, the insurer covers all of the hospitalization expenses along with the medical. Nonetheless, an insured needs only be registered to a network facility to gain the benefit of cashless hospitalization.

REIMBURSEMENT CLAIMS

Under this form of the settlement process, the policyholder must compensate in front of the hospitalization costs and then seek compensation from the medical company. One gets a redemption service for both network and non-network hospitals for any scenario.

The insurance company may provide a refund procedure or a cashless payment method. Yet how can you handle certain systems because you don’t realize how they work? Continue to see the specifics of the arguments.

Cashless Claim Process

To avail of the cashless claim facility, the insured has to be treated in an impaneled hospital. Through presenting the health insurance coverage information and sending the e-card or other actual evidence of the health insurance provided on behalf of the policyholder, he or she may use cashless hospitalization and care if the disease/injury is protected by the coverage. Once the patient is discharged from the hospital, all the medical bills are sent to the insurance provider by the hospital. The insurance provider then evaluates the expenses and settles the payment.

In this type of health insurance reform, the insurer covers all of the hospitalization expenses.
Image Credit: Insurance literature

The claims process for treatment at a cashless network hospital varies according to the type of treatment – Planned or Unplanned. Unplanned medical treatment at a cashless network hospital usually happens in case of an emergency.

  • Claims Process for Planned Treatment at the Cashless Network:

    Usually, the insured has to inform the insurance provider of the hospitalization or treatment requirement ahead of time to avail of cashless treatment. The company should be informed at least 4 days before the treatment date. A cashless claim request form should be submitted at the relevant address of the insurance provider – mostly via post, e-mail, or fax.

For more information, you can contact the customer care of your health insurance provider. Once these steps are completed, the insurance provider will notify the insured as well as the concerned hospital regarding the policy cover and eligibility. On the day of admission to the hospital, the policyholder has to display his/her health insurance card and the confirmation letter. The medical bills will be paid by the insurance provider, directly to the hospital.

Process for Planned Treatment 

  • Inform the health company about the care or hospitalization you are going to undergo when you allow the use of the cashless service. The company calls for details at least 4 days before the day of diagnosis. 
  • Submit a cashless claim request form to the address of the provider and reach out to the health insurance provider’s customer care number.
  • The patient and the facility involved must also obtain a scheme and compliance notification from the insurer. 
  • During hospitalization, the policyholder must display the confirmation letter along with the health insurance card. 
  • The company pays for the patient directly.
The medical bills will be paid by the insurance provider, directly to the hospital.
Image Credit: Money excel

Emergency Treatment at the Cashless Network for Claims Process:
The policyholder can contact the customer care help desk of an insurance provider to get information about the nearest network hospital. By displaying your health insurance card, you can avail of cashless hospitalization.

The hospital has to fill in the cashless claim request form and submit it at the relevant address of the insurance provider – mostly via post, e-mail, fax, or through customer care. An Authorization Letter will then be issued by the insurance provider to the hospital, indicating the policy coverage.

The medical bills will be paid by the insurance provider, directly to the hospital. In case of rejection of the claim, a letter will be sent to the insured, stating the reasons for rejection.

Process for unplanned treatment

  • Emergencies are unwarranted and require the policyholder to reach the hospital as soon as possible to undergo treatment. In such situations, the insured must provide the health insurance card to avail of cashless hospitalization at the ER. 
  • A cashless claim request form will be filled in at the hospital to be sent to the insurance provider, who will then issue an Authorization Letter to the hospital, indicating the extent of the coverage. Here too, the medical bills will be fulfilled by the insurance provider.
  • In the event of a rejection, the insured receives a letter or communication from the provider stating relevant reasons for refusal.

Reimbursement Claim Process

The reimbursement claim for health insurance can be made if the policyholder opts to go to a hospital of his/ her choice, which is a non-impaneled hospital. In this case, the cashless claim facility cannot be used. Therefore, the insured has to pay all his/ her medical bills and other costs involved in hospitalization and treatment and then claim reimbursement.

One gets a redemption service for both network and non-network hospitals for any scenario.
Image Credit: M Scribe

For compensation requests to be made eligible, you will supply the insurance company with the required paperwork and original bills. The insurer would then assess the lawsuit under the insurance cover and determine the extent and then offer a payout to the insured. In case the treatment is not covered under the policy, the claim will be rejected. The insurance provider generally provides reasons for rejection.

Reimbursement Claims- How it’s Done?

  • If the insured chooses a non-network hospital, (s)he has to pay all the medical bills, hospitalization, and treatment costs before submitting a claim for reimbursement. 
  • The insured has to provide all the necessary documents and the original bills to the provider, which will be evaluated for the scope of policy cover. 
  • Once inferred that the insured is eligible for the reimbursement, the amount will be transferred to the insured’s registered account. 
  • In case of a rejection, the provider notifies reasons for refusal to the insured. 
One have to submit every document while getting Reimbursement
Image Credit: Aging In Place

Documentation

The following documents are required to make a :

  • Duly filled claim form
  • Health Certificate / Form issued by the practicing practitioner.
  • Description of discharge or certificate (original), taken from the hospital.
  • All bills and receipts (original)
  • Prescription and cash memos from pharmacies/ the hospital.
  • Investigation report
  • The FIR or Medico Legal Certificate (MLC) is needed if this is an injury event.

Authorization Process for Health Insurance

If an insurer receives the intimation from the policyholder’s attendant and is informed regarding the same by the hospital (network), the insurer shall check the authenticity of the policyholder’s policy and policy scope. A field doctor is then appointed to support the referral for the pre-authorization document and to cross-check the diagnosis being reported. Upon testing, the insurance company’s compliance department accepts the policyholder’s cashless allegation according to the plan’s terms and conditions.

Important Conditions to Avail Health Insurance Claim

  • The authorization process may be canceled if the details are not filled.
  • Both charges have to be made within 30 days from the date of discharge.
  • The insured must compensate for all the things that are not available on their own.
  • To assert all of the post-hospitalization costs, the necessary documentation must be sent within 30 days from the date of discharge.

Important documents mandatory for health insurance claims

  • A duly filled and signed claim form. This is the document which can be downloaded online or obtained from the insurance office.
  • Investigation report
  • The initial payments, taxes, reports, etc. Every unpaid payment must pay for your failure.
  • A medical card, a case history, and all other paperwork that the doctor may register. It is almost of a registered recording of the record with sickness whilst in care.
  • Cash note for the medications bought from an approved pharmacy.
  • Discharge passport, review report, and other records including clearance.
  • An FIR would be stored whether there was a medical emergency, such as an injury or a casualty. Unless the FIR is not valid a Medico-Legal Certification is required.

After all, documents are duly verified and processed; the claim is deemed to be completed. The final move is to transfer the whole premium balance to the account of the company and is stated at the moment you buy the health insurance.

Usually, third-party administrators are responsible for verifying your documents and claims. Because benefits are better for restricting claims, they are taking strict action to cancel or deny any application that comes in. It is following the policy companies’ guidelines.

Health Insurance Premium Calculator

The Health Insurance calculator refers to the tool that assists a person in getting an estimate about the premium that he/she may have to pay on buying a new health plan or to renew the existing one in advance. The Health Insurance calculator saves a lot of your time during health insurance comparison. We have made the entire calculating process easier for you with the help of different parameters and filters as well.

The Health Insurance calculator saves a lot of your time during health insurance comparison.
Image Credit: Wish Policy

Factors Affecting Health Insurance Premium Calculations

Age: Your age plays a vital role in deciding the premium amount. Since you are more vulnerable to illness with the rising age and the premium level is still starting to climb.

Medical History: This plays a crucial function in estimating premiums. When in the past you are infected with some significant illnesses instead the rate for health care will rise accordingly.

Marketing & Services Expenses: All expenses associated with marketing and services are huge in numbers and insurance companies cover the same from their customers in the form of premium.

Savings & Investments: Insurance companies use to invest their capital in the public sector investment. The premium that you will pay is subject to the returns earned from such capitalizations.

Policy Underwriting: Companies analyze the possible risk from all angles into a wide range of factors that can cause trouble. On such a basis, they decide the premium amount.

Mortality Rate: Mortality is the cost that an insurer has to pay to your family in case of any medical emergency. Expenses associated with the same are also covered in the form of premium

Not Submitting Correct documents might get your insurance claim to be denied
Image Credit: India Mart

Benefits of Using Health Insurance Premium Calculator

There is no question that health care plans in one shot are pretty difficult to grasp, and each organization has its terms and conditions in this respect. This is possible because certain consumers are unsure of the conditions of the policy and will spend an additional fee to fulfill their standards.

It will be nice for these users to learn in detail about their expectations and anything relating to the program including how much fee you’ll have to offer. Sure, that would make the whole cycle of buying a health insurance program simple. Below are some fundamental benefits a health insurance calculator can offer.

  • By using a premium health insurance calculator you’ll get a preliminary idea or estimate of the premium for health insurance.
  • With the same, selecting the best plan that can easily go well with your needs and pocket as well will be fairly easier for you.
  • You may put any additional rider on removal.
  • It’ll make things simpler for you to choose what you will do next.

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