What Are The Types Of Health Insurance Claims And Its Process?
by SMCIB on Wed, Feb 15 2023
In today’s world of unhealthy food intake, lack of physical activity, and lifestyle choices, you never know when an unexpected medical expense will knock at your door. This is why buying a health insurance policy is important - to protect yourself and your family from such circumstances. All you have to do is pay the premiums regularly, and the insurer will continue to cover your healthcare expenses.
But how much do you know about making a health insurance claim? What are the types of health insurance claims available?
Making a health insurance claim might be a tedious and time-consuming task. And, with the mental distress of your or your family member being ill, you certainly do not want the added stress of a drawn-out claims process. This is why knowing about health insurance claims and their processes becomes crucial.
In this article, we take you through everything you need to know about the types of health insurance claims. So, let’s kick off!
Types of Health Insurance Claims
Let us begin by understanding the two common methods of making a health insurance claim.
In a cashless claim, the insurer directly settles your medical bills with the hospital. This means that you do not have to go through tedious paperwork or shell out any money from your pockets. All you have to do is initiate the claims process at the hospital’s insurance desk, and the rest will be taken care of.
It is a simple and convenient type of claim. The only thing you need to ensure is that the hospital you get treatment from is on the insurer’s network hospitals list.
Note: Any unapproved expenses will have to be borne by you.
When it comes to a reimbursement claim, you will need to pay the medical bills yourself first.
Once you’re treated and get discharged from the hospital, you will need to submit the necessary bills and documents to the insurer. After verification and approval, the insurance company reimburses the costs you have incurred.
This type of claim involves you doing the major part of the paperwork. In most cases, a reimbursement claim has to be made when you get treated at a hospital that is not a part of your insurer’s network hospitals list.
Now that we know about both claims, let us differentiate between the two.
Cashless v/s Reimbursement Claims
Both cashless and reimbursement claims work differently. Here are the main differences between the two:
Type of hospital
To make a cashless claim, you need to get treated at a network hospital, i.e., one that has a tie-up with the insurance company.
For a reimbursement claim, you can get treated at any hospital, whether it’s a network or non-network hospital.
The medical bills are settled directly between the insurance company and the hospital.
You initially pay the medical bills to the hospital and later get reimbursed by the insurance company.
Let us now see how the claim process works in both cases.
👉Cashless Claim Process
1. Check if the cashless claim is accepted at the hospital
With the tie-ups and arrangements getting revised often, make sure to check if the hospital is still under the network hospital list of the insurer. You can confirm this with the hospital desk.
Ask them about -
- The process for the type of policy you own - whether you have individual health insurance, a family floater, a group health insurance scheme, etc.
- The documents you need to submit, so the process becomes smoother.
- Any sub-limits for specific treatments so you are aware of the expenses that you will need to pay from your pocket.
2. Get a Pre-Authorization Request
During this process, the hospital insurance desk will contact the insurer on your behalf to get pre-approval for your treatment cost. For this purpose, you will have to submit the required documents and duly fill out your claim form. The hospital insurance desk will then take the process forward with the TPA or insurance company after submission.
3. Keep some cash handy
You should make sure that you always have some emergency money on hand or an active credit card at all times. Here are three reasons why -
There might be circumstances where the insurance desk at the hospital does not work 24/7. In such cases, you might be required to -
👉Pay an advance sum to get admitted for your treatment, or
👉Delay your discharge if the insurer’s final approval has been delayed.
Some hospitals may require you to pay a small advance even if your cashless claim has been approved by the insurer.
- If you can’t wait for the pre-authorisation by the insurer, especially during medical emergencies, you might need to pay an advance to the hospital to start the treatment.
Any advance you pay will later be refunded, either fully or partially, when the insurer approves your cashless claim request.
4. Submit Required Documents
Here are a few of the essential documents that you need to submit for a smooth cashless claim process:
- A cashless card or policy copy
- All past medical records related to hospitalisation
- KYC of the admitted patient
- A First Information Report (FIR) from the police department in case of accidents
5. Ensure that the following steps are taken care of progressively
- In case of planned hospitalisation, process the paperwork in advance. And in cases of unplanned hospitalisation, submit the claim form within 24 hours.
- Keep track of the progress through the TPA app or the insurer’s website. Be prompt in submitting documents and answering the queries raised by the insurer to avoid any delay or rejection of cashless claim settlement.
- Have extra copies of all submitted documents for future reference or further submissions to the insurer.
- Track the billing daily to avoid any errors or discrepancies in the claim. You can also be prepared to tackle any additional charges if the cover is insufficient. You can do so by either informing the insurer of additional charges incurred or making use of another health insurance policy to cover the same.
- Record all pre-hospitalization expenses, as they have to be claimed separately. Safely document all original prescriptions, bills, and reports (including films) that resulted in hospitalisation.
- Purchase medicines from the hospital pharmacy before discharge as they would get covered under the cashless claim too.
6. Be Ready for the Final Billing
When your discharge date is finalized, you must promptly take it up with the hospital insurance desk to submit all relevant paperwork like the final bill, discharge summary, and other documents to the insurer. Track the progress through the online tracker on the insurer’s website and send across any pending documents. The approval process takes anywhere from 2 to 6 hours once all relevant documents are submitted to the insurer.
In cases where the final approval gets delayed by the insurer, you can choose to wait at the hospital or pay in advance and later get reimbursement.
7. Know the Claim Approval Process
Here’s how the claim approval process works -
- The insurer will provide you with a claim settlement summary that clearly shows all approved and unapproved medical expenses.
- Expenses like copay, proportionate deduction, consumable items, and other exclusions will not be borne by the insurer.
- You can get the claim for any advances or deposit money made to the hospital.
- Any deductions in the policy due to a shortage of the available sum insured or limits/exclusions, etc. can be claimed from another health insurance policy on a reimbursement basis.
- Every cashless claim includes a reimbursement component for pre- and post-hospitalization expenses, which you can claim later.
👉Reimbursement Claim Process
A reimbursement claim process can be for –
- The entire treatment (right from the admission to the discharge expenses)
- Only pre- and post-hospitalization expenses in case of a cashless claim
- When one policy is used for a cashless claim and any remaining amount is claimed through reimbursement.
This is the process you will have to follow for a reimbursement claim -
1. Claim Intimation
The first step is to promptly inform the insurance company about your hospitalisation at least within 24 hours of admission. Get every detail, like the deadline for claim submission after discharge, documents to be submitted, etc.
2. Handling documents
The reimbursement process runs smoothly when you submit all documents promptly. All relevant paperwork from the date of disease discovery to the period of recovery, like prescriptions, receipts, bills, X-rays, MRIs, etc. You can then submit all such documents along with the duly filled claim form.
The required documents generally include -
- A copy of the policy document, your health card, or a policy copy.
- Photo ID.
- Claim form is to be filled and signed. A part of this form has to be filled out by the hospital with the doctor’s signature.
- All medical bills, tests, and prescriptions leading to hospitalisation prescriptions for medicines, and medical tests, including prescriptions from the first doctor you visited, with a complaint leading to this hospitalisation in the original.
- All original pharmacy bills, discharge summary, and test reports, including films & CDs (X-ray, MRI).
- Discharge summary from the hospital in the original.
- Your bank details can be provided through a cancelled cheque for the NEFT transfer of your reimbursement. Note that insurers do not send cheques; they only make online transfers.
- In case of an accident, an FIR, a medico-legal certificate, or a summary of the accident may be required.
Note: Any additional documents as and when required by the insurance company must be submitted for a smooth claim process. Also, ensure you have photocopies of all medical documents you submit to the insurer for future reference.
You must keep a close watch on the insurance company’s portal or app as they might raise any queries or requests for additional documents from time to time. Hence, ensure that you track the claim status regularly and address them at the earliest.
3. The Claim Settlement
The insurer will credit the reimbursement amount to your bank account. They will send a detailed summary of the approved and unapproved medical expenses. Make sure that you check every detail and inform the insurance company in case of any errors.
Now that we have come to the end of this article, we hope that you have gained enough knowledge about the types of health insurance claims and how they are processed. This will help you handle a claim situation well and act prudently.