There are two methods for getting a claim under a health insurance policy
1. Cashless Hospitalisation
2. Non-cashless Hospitalisation
In case of Cashless/planned Hospitalisation
1. In case of planned hospitalization inform the TPA/insurance company about the date of admission in the hospital quoting your policy number and health ID card atleast 4-5 days in advance.
2. The form for intimation to TPA and obtaining pre authorization for cashless claims services is available with the admission counter of the hospitals.
3. The patient must fill up the form carefully as any incorrect information may lead to rejection of pre authorization.
4. The medical condition of the patient or the requirement of any surgical procedure is filled up by the doctor attending the patient. Be sure that the doctor is briefed correctly about the patient’s history, otherwise it may again lead to rejection of preauthorization by TPA.
5. In case of new policies all pre-existing diseases are excluded. At the time of signing pre-authorisation form check that doctor has not mentioned anything about condition which may lead to assume it for pre-existing.
6. The filled up form is then sent by the hospital authorities to the respective TPA of the company for granting of pre-authorisation of amount for hospitalization.
7. The TPA carefully scrutinises all the details such as policy number, validity of policy, sum assured, waiting period, preexisting diseases etc and after being satisfied sends the authorization of amount directly to the hospital.
8. After satisfying itself the TPA will issue a preauthorization letter/ guarantee of payment letter to the hospital/nursing home mentioning the sum guaranteed as payable and also the ailment for which the person is seeking to be admitted as a patient.
9. The TPA has the right to deny the preauthorization if he is not satisfied with the documentation.
10. Unless the TPA gives the pre-authorization letter to hospital, the hospital will not treat it as cashless claim. So the insured must vigorously follow-up with the TPA for giving the authorization letter.
11. If the letter from TPA is not received or if they deny then the insured must first pay for the expenses from his pocket and then lodge a claim to the TPA/insurance company.
12. In case of planned hospitalization it is easier to get pre-authorisation since the insured has ample time to followup with the TPA. The problem comes in emergency hospitalization.
Here time is of essence. The hospital will not start treatment unless he receives authorization from TPA or cash from the insured.
13. This creates a panic situation and many times the insured are forced to pay from their
pocket and thereafter claim the amount from TPA/Insurance Company in normal course due to emergency. In many cases it has been seen that TPA’s delay the process of authorization so that the customer pays from his pocket and then claims reimbursement.
14. Generally the TPA’s grant authorization for a particular amount. If the cost of treatment exceeds that amount the patient must give it from his own pocket and then claim reimbursement from the Insurance company if it is within the policy limits.
In case of Non-Cashless Hospitalisation/Emergency Hospitalisation:
In case of Non cashless Hospitalisation the insured must give preliminary intimation about the claim within 7 days of hospitalization (The intimation period may vary from company to company) to the TPA/Insurance Company.
The notice would include the following:-
1. Particulars of Policy number
2. Health ID card number and copy
3. Name of Insured Person
4. Address
5. Name of attending doctor
6. Name of Hospital
7. Nature of illness/injury
After the insured is discharged the final claim must be submitted to the company within 30 days from the date of discharge. The period of intimation may vary in insurance companies.
The following documents must be attached along with the prescribed claim form of the company:-
1. Original prescription of Doctor
2. Prescription of doctor advising for hospitalization/tests.
3. Original reports of all diagnostic tests along with the original bills like X-rays, ECG, Scan, MRI, Pathology etc.,
4. Detailed itemized bill from the hospital for bed charges, OT charges, medicines, and details of any other charges that the hospitals have levied.
5. Surgeons certificate stating nature of operation along with bill.
6. All bills for medicine purchased during the previous 30 days before hospitalization and
after discharge.
7. Hospital Receipts / bills / cash memos in Original (Copies of charge slips if payment is made by credit card) duly stamped.
8. Discharge certificate from hospital
9. Certificate from the doctor that the patient is fully cured and is able to resume his work
10. In case of domiciliary hospitalization a report from qualified nurse who attended the patient in his residence supported by a certificate from medical practitioner.
11.Copy of current insurance policy and previous policy.
12. F.I.R. in the case of accidental injury and English translation of the same, if in any other language.
13. The claim form must be filled correctly and there should not be any overlapping of information otherwise it may lead to rejection of claim.
14. Since all the original documents are submitted along with the claim form the policyholder must keep a copy of the claim form and all the original documents submitted along with the claim form. At the time of submitting the claim form he must obtain an acknowledgment from the insurance company about the receipt of the documents to serve as a proof of submission.
15. The policyholder must followup with the insurance company about the status of the claim after some time as the insurance company may require some other documents or clarifications from the hospital about the charges.
16. The insurance company if finds everything in order shall make payment for the claim. Many times it deducts some amounts from the bill which are not authorized under the policy or which may seem to be in excess.
