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Health Insurance Claims Processing

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Health Insurance Claims Processing
October 30, 2018
Taking out a health insurance policy is absolutely necessary for securing your money and your family’s finances. It acts as a sure-shot guarantee in times of requirement and allows you to retain your financial strength. In fact, health insurance is the most common and essential form of insurance scheme, among other types of insurance. Before applying for a health insurance, you must know how to choose the proper type of insurance policy and the ideal insurance cover for you and your family. This means choosing the best add-on features and being careful about various application sub limits, what are capped under it and what are not. You must know about the kinds of medical check-ups that may be required before accepting any policy. Being aware of the insurance claims processing beforehand is equally important.
 
The insurer processes every claim received from two approaches - cashless or reimbursement claims, and on the basis of network or non-network hospitals.


In a cashless claim, the policyholder is not expected to pay the hospital bills as the insurer reimburses the same. If treatment was availed through network hospitals listed with your insurer, you generally don’t have to pay anything to the hospital. Your insurer or their third party agents (TPA) will take care of your bill and settle it with the hospital directly. Request for cashless claim needs to be placed by submitting a hardcopy or through customer care. Request can even be placed online, which is more convenient.

In a reimbursement claim, the policyholder has to pay the hospital bills and then it is reimbursed by the insurer. 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-empanelled 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. In order to avail reimbursement, claim you have to provide the necessary documents including original bills to the insurance provider. The company will then evaluate the claim to see its scope under the policy cover and then makes a payment to the insured.

In case of a cashless claim, follow the steps given below:

Step 1:

Check whether the illness is covered in your policy. Also, check if the hospital is a network hospital.

Step 2:

Inform your insurer about the hospitalization within 24 hours. You will be asked to fill a Pre-Authorization Form and submit it at the TPA (Third Party Administration) counter at the hospital. They will then forward the form to the insurer for approval.

Step 3:

You will be required to submit documents like Cashless Health Card provided by the insurer and other KYC documents for identification.

Step 4:

Once insurer approves your claim, the original documents pertaining to hospitalization will be retained by them. For your records, you must keep a copy of these documents.

Step 5:

Retain the pre and post hospitalization bills and associated prescriptions/medical reports to claim them later. It is advisable to check the coverage of these expenses in your Policy Document.

In case of reimbursement (i.e. when you don’t opt for a cashless facility or when the hospital is not covered in the cashless network), following are the steps followed:

Step 1:

Inform the insurer. Fill and submit the reimbursement claim form within 30 days from the date of discharge. This form is available with the insurer.

Step 2:

Get the original copies of medical reports, medicine bills and hospitalization bills stamped and signed and submit them along with the claim form.

Step 3:

Submit the Discharge Summary/Card to the insurer.

Step 4:

Submit your doctor’s follow-up prescription in original to the insurer. Submit post hospitalization expenses bill within 30 or 60 days from discharge as per the terms of your policy.

Step 5:

Retain copies of all the submitted documents for future reference and wait for the settlement of your insurance claim. (Generally, the claim will be settled in 2-3 weeks)

HDFC Life offers various health insurance plans and with an extremely impressive claim settlement ratio, we seek to protect your finances from any risks due to health related contingencies. For details, click on the mentioned link: https://www.hdfclife.com/health-insurance-plans

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Francis Rodrigues Francis Rodrigues

Francis Rodrigues has a decade long experience in the insurance sector, and as SVP, E-Commerce and Digital Marketing, HDFC Life, manages the online sales channel, as well as digital and performance marketing. He has had hands-on experience in setting up sales channels and functional teams from scratch over a career spanning 2 decades.

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Vishal Subharwal Vishal Subharwal

Vishal Subharwal heads the Strategy, Marketing, E-Commerce, Digital Business & Sustainability initiatives at HDFC Life. He is responsible for crafting and ensuring successful implementation of the overall organisation strategy.

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