Reimbursement and Cashless Claims Procedure for Health Insurance Policies

Reimbursement and Cashless Claims Process in Health Insurance Plans

Wondering, about reimbursement and cashless claims procedure for health insurance? For the past two years, we have been dealing with COVID-19, which keeps coming in phases. While India sees a surge in COVID cases almost every alternate month, we have another disease now called Monkeypox. In a situation when we may contract this kind of virus at any moment, it is quite important to take care of our immunity. Along with this, it is also important to have health insurance plans. As a matter of fact, even if you need to be hospitalized, your health insurance policy can make it easier for you to clear the medical bills. You can either choose a cashless bill settlement or reimbursement.

Why should I buy health insurance when I'm young and healthy?

As far as the reimbursement meaning is concerned, you pay the bill from your pocket and later submit the documents to the insurer and then the insurance company reimburses the money to you. To talk about the cashless claim, you just have to inform the insurer, and the bill will be settled by them at the hospital. Let us know about both options in length here.

Medical Insurance Cashless Claim Process

To avail of the cashless health insurance claim facility, you have to undergo your treatment in a network hospital. However, you need to know that the cashless claim process for treatment at a network hospital may vary. It totally depends upon the type of treatment, whether it is planned or unplanned.

The cashless claim process for a planned treatment at a network hospital

You can avail of a cashless treatment only at a network hospital. And, if it is a planned treatment, you have to follow the steps mentioned herein below:

• You would be required to submit the cashless claim form to the insurance company from where you have bought the policy. You can do it through a letter or an e-mail at least five days prior to your date for treatment.
• Once the cashless claim form is received by the insurance company, they will inform the hospital about the same.
• You will then receive a confirmation letter. The validity of this confirmation letter will come with a validity period of seven days from the date of issue.
• You have to submit the confirmation letter as well as the health card before you take admission to the hospital. All the expenses will be borne by the insurer.

The cashless claim process for emergency treatment at a network hospital

In case of emergency treatment at a network hospital, you need to follow the below-mentioned steps:

• The insurance provider has to be notified within 24 hours of hospitalization. Once it is done, your Reference Number, which is also called Claim Intimation, is generated.
• The hospital has to fill in your cashless claim form and even submit it to your insurance provider.
• The insurance provider will send an authorization upon receiving your cashless claim form.
• The medical expenses incurred will be cleared by the insurer. In case, the claim is rejected, you will receive a notification on your e-mail address and registered mobile number.

Reimbursements Claim Process

A reimbursement claim for health insurance is usually made when the policyholder either undergoes treatment at a network hospital but couldn’t avail of a cashless claim, or if the insured undergoes the treatment at a non-empanelled hospital. In a reimbursement insurance claim process, the insured has to pay the medical bills from his/her pocket and later get it reimbursed from the insurance company. Here are the steps that have to be followed for the reimbursement claims process.

• You would be required to submit all the relevant documents to the Third Party Administrator once you are discharged.
• The documents will be reviewed by your insurance provider. However, you have to be patient enough since your insurer may take up to 21 days to review the documents and even process the payment.

In case the insurance company has some kind of query or if the claim has been rejected, you will be notified accordingly.

Documents Needed to Claim Health Insurance

While filing a medical claim, you have to submit certain documents. Here are some of them mentioned below:

• Health card
• Duly filled claim form
• Medical Certificate which is signed by the doctor who did the treatment
• Each of the original bills and receipts
• Original discharge summary or card that you received from the hospital
• Investigation report
• Prescriptions and receipts from pharmacies or the hospital
• If the treatment is required because of an accident case, then the FIR or Medico-Legal Certificate will be important.

Disputes and Complaints

As the process of claiming the insurance is subjective, it is possible that you are dissatisfied with the outcome of their claim or the time it takes in progressing the claim. The insurance-related disputes and complaints can be brought to the notice of the Insurance Ombudsman under the Insurance Ombudsman Scheme according to the Redressal of Public Grievances Rules, 2017. A policyholder can do that if he/she does not receive a response from the insurer within a month of filing the claim.

For the complete details and added information, the policyholder has to refer to the respective Product Policy Copy.  One of the most important things to consider is the policy documents of your current insurance provider’s Copy of the Insurance Renewal notice, or policy schedules of the previous three years.

When it is a medical emergency, it becomes quite challenging to figure out the documentation and even the claim process. However, to get benefits from health insurance cover, it is quite important to think everything ahead and keep the documents in place, as much as possible.