How to Navigate the Insurance Claim Process Smoothly?

Overview of the Health Insurance Claim Settlement Process: 

The basic steps of insurance claim settlement involve the following:  

1. Claim Reporting: 

The settlement process begins only when you inform your insurance provider about your admission into the hospital or the beginning of any treatment, be it planned or under emergency. 
 
Pro tip: Emergency claims must be intimated to the insurer within 24 hours of hospitalisation, while planned claims need prior approval at least 3-4 days before hospitalisation. 
 
Even if you do not wish to file a cashless claim, it is prudent to keep your insurer informed. 

2. Submission of Documents:  

The insurance company will ask for certain documents either during the treatment or after it, including hospital bills, medication prescriptions, pharmacy bills etc. to asses the requirement.  
 
For cashless claims, your hospital will liaise with the insurer on your behalf and provide all the original documents for the claim settlement process.  

However, for Reimbursement Claims, you must submit all the original documents to the insurer, along with a duly filled and signed claim form and your bank account details for the claim to be processed. 

3. Claim verification:  

To evaluate the authenticity of your claim, the insurance provider will verify all documents and information you provided.  

Pro tip: Adjudication of claims refers to the process by which your provider decides whether to settle or reject your claims based on your policy terms and conditions.  

4. Settlement of Claim:  

The company decides after thoroughly reviewing your situation and condition and prior claim history. If the claim is approved, the funds are directly paid to your hospital in Cashless Claims or reimbursed to you after subtracting any deductibles or co-payments in Reimbursement Claims.  

Types of Claims and Their Process  

STEPS OF THE CLAIM PROCESS	TYPES OF HEALTH INSURANCE CLAIMS
	Cashless Claims: Only applicable if admitted to network hospitals of the insurer.		Reimbursement Claims: If you need to admit your patient to non-empanelled hospitals or if the cashless process is delayed by the hospital, the reimbursement process is followed.
	Cashless Planned Hospitalisation	Cashless Emergency Hospitalisation
Step 1	3-4 days before hospitalisation, a cashless claim form is to be submitted to the insurer via letter or email.	The insurance provider is to be notified within 24 hours of hospitalisation. A claim intimation number is then generated and shared with you	The insurance company should be intimated via email or call within 2 days of hospital admission.
Step 2	Once the form is received, the insurance company will inform the hospital	The claim insurance form needs to be filled out by the hospital with all details and submitted to the insurer.	The claim form from the insurer’s website needs to be downloaded and filled.
Step 3	The insurer will send you a confirmation letter with a validity of 7 days from the date of issue.	The insurance provider sends an authorisation post-receipt of your claim form.	Several documents like discharge summaries, doctor’s bills, test reports, and in-patient records are to be submitted along with parts A and B of claim forms.
Step 4	The confirmation letter and your health card will be submitted to the hospital to enjoy the cashless benefits.	The expenses incurred are cleared by your insurer directly with the hospital. In case of claim rejection, you will be notified by email or via message.	The insurance company or the Third-Party Administrators (TPA) will check in detail all documents submitted and if approved, settle the claim via bank transfer with a TAT of 10-15 working days.

 

List of Documents Required for Insurance  Claim Settlements: 

Along with the claim form, these documents are critical to be submitted for claim clearance :  

1. Discharge Summary report from a hospital in original 
2. Original bill payment receipts for all investigations and doctor consultation 
3. Original Doctor prescriptions 
4. Medicine Bills in original from the hospital pharmacy 
5. A copy of inpatient records for each day is needed. 
6. A copy of valid age  proof ( like an aadhaar, PAN, passport or driving license)  
7. A copy of the attested hospital registration certificate 
8. Bills and prescriptions from 30 days pre-hospitalisation and 60 days post-hospitalisation to claim expenses before and after.  
9. To facilitate bank transfer, a cancelled cheque with the policyholder's name and account number printed, or a passbook copy. 
10. In some cases, extra documents may also be asked for better clarity and query resolution.  

However, there may be delays even after submitting all things required. To reduce insurance claim delays and rejections, certain checks are needed to be done at your end :  

1. Timely notification needs to be given to the insurer as specified in policy terms and conditions. Hence, you need to read your policy documents thoroughly.  
2. Understand the policy coverage rules, the waiting period for pre-existing diseases,  sub-limits and co-payments that are a part of your policy first before raising a claim.  
3. The claim may be rejected if false information is provided while issuance of the policy and in case the insured is involved in any fraudulent activities.  
4. Claims may also be denied if admission to the hospital is only for investigation purposes and not for treatment unless otherwise mentioned in the policy.  

To reduce delays for such reasons and to streamline the operation, a Third Party Administrator (TPA)  is brought in to ease out the insurance claim process in the  following ways :   

1. After a validation procedure for every policyholder, the TPA issues a health card which gives the hospital and the insurance provider information about the policyholder, the policy number and the TPA responsible for the service. During cashless insurance claims, TPA collects all documents from hospitals directly and fills up the claim forms.  
2.  Value-added services like ambulance pick-ups, extra consultation facilities, wellness programs and a 24*7 client servicing helpline are provided by these TPAs. 
3. In addition, TPAs have a robust and well-connected network of hospitals with best-specialised medicine practitioners and thus can provide hassle-free cashless insurance claims