Reimbursement & Cashless Claims Procedure

What is Covered under Health Insurance Claims?

The insurance company will provide coverage if you are diagnosed with any kind of medical condition, injuries and require medical assistance including surgeries. The insurance company will also cover your stay in the hospital and the price of medicines and other similar items. 

Make sure your condition is not pre-diagnosed before you avail the health insurance policy, and you don’t seek any kind of cosmetic surgery. In these cases, the insurance company can refuse to provide insurance coverage. 

What is Not Covered under Health Insurance Claims?

Given below are the conditions for which the insurance company may refuse to provide coverage. They are: 

1. Pre-existing illnesses 
2. Cosmetic surgeries 
3. Complications related to infertility or pregnancy 
4. Cost incurred for alternate therapies  
5. Complications due to consumption of drugs, alcohol, or smoking 
6. Health supplements 
7. Diagnostic charges unless part of an on-going treatment 

Eligibility Criteria for Health Insurance Claims

The eligibility criteria to avail a health insurance policy is very simple: 

1. You must be aged between 18 years and 65 years. Some insurers also allow people aged 70 years and above to apply for a health insurance policy. 
2. You must not be diagnosed with any pre-existing illness. 
3. For the claim process, have all your documents in place and inform the insurer about the treatment immediately. 

Documents Required for Health Insurance Claims

The documents you will need to submit during the claim process are given below: 

1. Duly filled claim form 
2. Health Card 
3. Consultation papers provided by your doctor 
4. Hospital bills including all the receipts stating the payment done by you 
5. Diagnosis reports 
6. FIR or Medico Legal Certificates if required 
7. Payment receipts and invoices provided by the pharmacy during the purchase of medicines and other items 
8. Summary of the discharge of the patient 
9. Any other documents as asked for by the insurer 
10. Your health insurance policy documents 

What is Reimbursement in Health Insurance?

On visiting a hospital or getting yourself diagnosed, you can ask your insurer to cover the cost. In this case, the bill will be sent to the health insurance company, who will review the bill and if everything is in order will reimburse the amount. 

The reimbursement can be done either directly or indirectly. If you have initially paid out of your pocket, you can send the bill to the insurer who will post verification and will disburse the amount to be reimbursed to your bank account.

The other way is to directly send the medical bill to the insurer who will settle the bill with the hospital and clear your bills. 

Reimbursement Health Insurance Claims Procedure

1. Under this type of claim process, you can pay the medical bill upfront to the hospital and send the bill and other documents to the insurer who will verify it and if everything is in order, will reimburse the amount to your bank account.  
2. Here, you can get treated either in a network or a non-network hospital and pay the amount after which upon sending the bill to the insurer they will reimburse the amount to you.  
3. There are many deadlines that the insurance companies will provide to you to complete the reimbursement claim. If a patient is receiving the anticipated medical care, you will be required to notify the hospital and the patient two days prior to admission.  
4.  If an emergency prevented you from notifying the insurance in time, you should do it right away after being admitted to the hospital. If a person is urgently admitted to a non-network hospital, you must inform the insurer within 24 hours of getting admitted including the health status of the person admitted.  
5. If you are unable to follow any of the claim processes mentioned above, you can avail yourself of a third alternative. Once the person admitted to the hospital has been discharged, you can then proceed to submit the reimbursement claim to the insurer. However, this must be done within 7 days to 15 days of the date of release from the hospital. 

Benefits of Reimbursement in Health Insurance

 The benefits of reimbursement in health insurance are given below: 

1. Suitable option if you incur a high medical bill. 
2. Provides you flexibility in terms of managing your expenses. 
3. The reimbursement process is also hassle-free. 

Cashless Mediclaim Process for Indemnity Plans

The majority of fundamental medical insurance plans come within the indemnity plan. According to their name, indemnity-based health plans essentially cover the policyholder's hospitalisation costs up to the full amount of coverage. 

There are two ways through which you can file a claim for indemnity plans – reimbursement and cashless modes. 

1. Under a cashless mediclaim process, the bill amount incurred is directly paid by the insurer to the hospital. However, it is important that you notify your insurer well in advance and get yourself treated at one of the insurer’s network hospitals so that your claim process can take place in a hassle-free manner.  
2. A cashless plan, however, does not imply that the policyholder will not be required to pay anything out of their pocket.  
3. Certain expenses, like consumables, might not be covered by the policy; the policyholder is responsible for covering these expenditures.  
4. If the insured has chosen a cashless hospitalisation plan, they just need to pay a set sum, while the rest of the amount will be covered by the insurer.

How to Claim Reimbursement for Pre- and Post-Hospitalization Expenses

The majority of health insurance policies include coverage for relevant costs incurred before and after hospital discharge as well as for hospitalisation costs. The insurance is required to pay back the costs incurred around 30 days before the hospitalisation and 60 days after release. 

You may add these costs when filing your claim if your whole request is being reimbursed. 

However, if the hospitalisation was cashless, you might need to submit a second reimbursement application. According to the insurance company's terms and rules, the medical bills for the illness for which the insured was hospitalised must be presented.

The insurer will reimburse the appropriate pre- and post-hospitalization costs after verification within a predetermined time frame. 

How to Make a Health Insurance Claim? 

Given below are the steps to make a health insurance claim: 

1. Visit the preferred network hospital 
2. Present your cashless card at the hospital 
3. Complete and send the Cashless Request Claim Form to the Third-Party Association (TPA). 
4. Make sure you have a valid photo ID and your policy number. 
5. Submit the pertinent paperwork needed for the procedure. 
6. Your insurer and the TPA will work together to create a pre-authorization form. 
7. Following verification, the insurer will approve the payment for the cost of the necessary therapy. 
8. Ensure that you bring all of your medical history and hospital bills with you. 

If you decide to get treated at a non-network hospital, then you will have to initially pay the medical bills out of your own pocket. Keep the bills in place and notify the insurer immediately. Send the bills along with all the necessary documents to the insurer who will verify them.

If everything is in order, then the amount spent by you will be reimbursed to you by the insurer. 

Claiming Health Insurance from Multiple Insurers

You only need to file one cashless claim with any one insurer if you have health insurance plans from various insurance providers to cover all of your medical costs. Contact the second insurer for payment of the outstanding medical costs once the first insurer has resolved your claim. 

 You must provide the second insurance provider with the first insurer's claim settlement summary, attested hospital bills, and payment receipts. The insurer will evaluate your claim considering the terms and conditions of your policy and pay you the appropriate amount. 

Ways to Avoid Health Insurance Claim Rejections

Given below are some of the ways through which you can avoid getting your health insurance claims rejected: 

1. Make sure your insurance provider is aware of any existing medical conditions you may have. 
2. Do not forget to notify your insurance provider within the required timeframe of any emergency or planned hospitalisation. 
3. Before filing a claim, make sure to carefully review the inclusions, exclusions, procedure to file your claim, waiting periods, and other features and advantages of your policy. 
4. Send your insurance provider the required documentation in the original form. 
5. Enter a network hospital and take advantage of the cashless claim services there. 

Cashless Claim Process for Planned Treatment

In order to avail the cashless claim facility, the insured has to be treated in an empanelled hospital.

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.

The cashless claims process for planned treatment is as follows:

1. You have to submit the cashless claim form to your insurer through letter or email at least five days before the treatment date.
2. The insurance company will inform the hospital after receiving your cashless claim form.
3. You will receive a confirmation letter which will be valid for seven days from the date it was issued.
4. Submit the confirmation letter and health card before admission. Your medical expenses will be paid by the insurance company.

Cashless Claim Process for Emergency Treatment

The cashless claims process for emergency treatment is as follows:

1. You have to notify your insurance company/third-party administrator within 24 hours of hospitalisation. Your Claim Intimation/Reference Number will be generated.
2. The hospital should fill in and submit your cashless claim form to your insurer.
3. An authorisation will be sent to the hospital by the insurance company on receiving your cashless claim form.
4. Your medical expenses will be paid by the insurance company. If your claim is rejected, you will receive a notification about the same on your email address and registered mobile number.

GST rate of 18% applicable for all financial services effective July 1, 2017.

Disclaimer: Premiums may vary depending upon factors like age, location and prevailing taxes/GST.