Which Health Insurance Claim Is Best?

by SMCIB on Tuesday, 13 June 2023

Which Health Insurance Claim Is Best?

In today's world, one cannot honestly, truly say that they are in the pink of health. Whether you are dealing with one of the many surging viruses, battling with some lifestyle disease, or feeling mentally drained, down or just off - you are not alone. Life has become an unpredictable roller coaster ride. But amidst all of it, the one thing you can bank on for some financial relief is your Health Insurance policy.

After doing extensive research, you finalise one plan that fits you perfectly. You pay your premium regularly, hoping that if the time ever comes, it would protect you against medical expenses. But when it actually comes to claim settlement, you feel left in the dark. With our own assumptions, we have termed the claims process as something complex. However, with proper awareness, it can really be smooth and hassle-free!

Today, let’s simplify Health Insurance claims to the T, and find out the easiest process to go around!

What is a Health Insurance claim?

It is the process of requesting your insurer to cover any healthcare expenses you incur. The insurer will first verify the claim. If it is accepted, they’ll settle the bills directly with the hospital, or reimburse you for the amount you have spent. This will depend on the type of claim process you have opted for.

Types of Health Insurance claims and how they work

Health Insurance can, generally, be claimed in 2 ways, by going for either -

Cashless Claim

  • To apply for this, you need to get treated at a network hospital listed with your insurance company

  • If your preferred hospital is on your insurer’s approved list of cashless hospitals, they will settle the medical bills directly with the insurer

  • You are responsible for paying only any expenses that are not covered by your plan.

For eg., Tamanna meets with an unfortunate accident, for which she is admitted to a hospital for 72 hours. The cost of medical treatment, doctor’s fees, and hospital bills come up to Rs. 70,000. Since the hospital is under her insurer’s network list, she can get all her treatments done and then simply follow the cashless claim process. The insurer will settle the claim amount with the hospital.

Reimbursement Claim

  • When it comes to a reimbursement claim, you will need to pay the medical bills yourself first

  • Once you are treated and get discharged from the hospital, you will need to submit the necessary bills and documents to the insurer

  • Once the insurance company verifies and approves them, they will reimburse the costs you have incurred

  • You can get treated at any hospital of your preference.

For eg., Aadil needs to undergo coronary artery bypass surgery. He gets admitted to one of the best cardiology hospitals, which is not under Aadil’s insurer’s network list. So, he will need to apply for a Reimbursement Claim. The cost of medical treatment, doctor’s fees, and hospital bills come up to Rs. 3 lakhs. Aadil will need to pay for all the expenses upfront before getting discharged. And then he will have to submit all his hospital bills, prescriptions, and medical documents to his insurer. Once approved, the insurer will reimburse the expenses incurred.

How do the 2 Claims Processes work?

Cashless Claim Process
  1. Check if the hospital accepts cashless claims

    The tie-ups and arrangements get revised often. So make sure you confirm that the hospital you have chosen is still under the network hospital list of your insurer.

  2. Enquire about your claims process and the documents required

    Once confirmed, 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 may need to submit

    • Any sub-limits for specific treatments that will not be covered - so you are aware of the expenses you would need to pay from your pocket

  3. Get a Pre-Authorization Request

    The hospital insurance desk will contact the insurer on your behalf to get a pre-approval for your treatment cost. This step is called the pre-authorization process. For this, you will have to duly fill out your claim form and submit the same with the required documents to the hospital desk.

    After submission, the hospital insurance desk will take the process forward with the TPA (intermediary between you and your insurance provider), or directly with your insurer

  4. Keep some cash handy

    Make sure you always have some emergency money handy, or an active credit card at all times. The insurance desk at the hospital might not work 24/7. In such cases, you might be required to -

    • Pay an advance sum to get the treatment started, or

    • Delay your discharge, if the insurer’s final approval has been delayed.

    Note: Any advance you pay will later be refunded, either fully or partially, when the insurer approves your cashless claim request.

  5. Be ready for the final billing

    When your discharge date is finalised, contact the hospital insurance desk and submit all relevant paperwork, like - the final bill, discharge summary, and other documents. Track the progress through the online tracker on the insurer’s website and send any pending documents. Once all documents are submitted, the approval process takes anywhere from 2 - 6 hours.

    If the final approval gets delayed by the insurer for some reason, you can choose to wait at the hospital, or pay in advance and later get reimbursement.

    Note: You will be given a claim settlement summary document by the insurer, which will contain information about the approved and unapproved expenses.

Reimbursement Claim Process

It can be for –

  • The complete treatment (right from the admission to the discharge expenses)

  • Only pre and post-hospitalization expenses, in case of a cashless claim

  • A situation where a cashless claim is opted for, but some remaining amount is claimed through reimbursement

The steps that need to be followed for any of the above cases-

  1. Claim intimation

    The first step is to promptly inform the insurer 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. Document submission

    All relevant paperwork - from the date of disease discovery to the period of recovery, like prescriptions, receipts, bills, X-rays, MRIs, etc. - need to be submitted, along with the duly filled claim form.

    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. Any additional documents as and when required by the insurer must be shared, for a smoother claim process.

  3. Claim settlement

    Once the claim is verified, the insurer will send a detailed summary of the approved and unapproved medical expenses. Make sure to check every detail, and inform the insurance company in case of any errors. Once that's done, the reimbursement amount will get credited to the bank account mentioned by you in the claim form

Which Health Insurance claim is the best?

Now that we have understood both processes, let’s address the main question!

As you could see, a Reimbursement Claim involves you doing a major part of the paperwork. And that could take a toll on you, while you are already dealing with a medical condition. However, if you don’t find a hospital of your choice in the insurer’s network list (if they are too far away, or don’t have the required treatments available), you should go for a Reimbursement Claim. This gives you the option to get treated at your preferred hospital.

On the other hand, a Cashless Claim saves you a significant amount of time and effort, as you won’t have to go around gathering documents, submitting them, and following up with the insurer. The hospital insurance desk will handle the claim on your behalf. It is a convenient and hassle-free way, as you won’t have to arrange for a large sum of money at the time of hospitalisation. The only thing you’d need to ensure is that the hospital you get treated at is on the insurer’s network hospital list.

Wrapping Up

Health Insurance, as a product, is largely personal. It works best when tailored to your unique needs. Similarly, the claims process you should choose, whether cashless or reimbursement, depends on the kind of experience you are looking for. We hope you assess your needs, analyse both options and opt for the one that truly helps you in your time of distress.

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