Health Insurance claims are processed in two ways:
1. Cashless Settlement:
You may be eligible for cashless treatment at hospitals that are included in your health insurance provider’s network list. In this case, the third-party administrator or insurance company will settle the cost of treatment and related expenses directly with the hospital, without involving you.
2. Reimbursement of Medical Expenses:
If you have a medical emergency and receive treatment at a hospital that is not on your health insurance provider’s network list, you will need to pay for the expenses out of your own pocket and then make a claim for reimbursement. However, due to the high costs associated with medical treatment, reimbursement may not be the preferred option for many.
Procedures :
For Cashless Settlement:
- Contact the insurance company and the Third-Party Administrators (TPA) at least 2-3 days in advance, and within a maximum of 24 hours of hospitalization in case of a medical emergency.
- Get admitted to a hospital that falls under the network list of the health insurance provider.
- The TPA Desk at the Hospital will assist both the insurance company and the policyholder in terms of documentation.
- Submit the necessary documents to the TPA Desk at the Hospital, including your health insurance policy details, identification proofs, medical reports, etc.
- The insurance company evaluates the claim against the coverage and terms and conditions of the policy.
- If the claim is approved, the insurance company settles the cost of treatment and related expenses directly with the hospital.
- If the claim is denied, you will have to pay the costs from your pocket and later apply for reimbursement.
For Cashless Settlement:
- Inform the insurance company immediately after getting admitted to a hospital, even if it’s not a network hospital.
- Submit the necessary documents to the TPA Desk at the Hospital, including your health insurance policy details, identification proofs, medical reports, prescriptions, bills, receipts, etc.
- The insurance company evaluates the claim against the coverage and terms and conditions of the policy.
- If the claim is approved, the insurance company will reimburse the cost of treatment and related expenses to you.
- If the claim is rejected, the insurance company will send a claim rejection letter, mentioning the reasons for the rejection.
Important points to consider:
- A minimum of 24 hours of hospitalization is mandatory to make a health insurance claim (except for daycare procedures where 24 hrs. hospitalization is not necessary).
- Follow the time frames specified by your health insurance company to avoid any issues in the claim process.
- Understand the coverage and exclusions of your health insurance plan before filing a claim.
- Maintain proper documentation of prescriptions, medical reports, bills, receipts, etc., to ensure a smooth claim process.
- Cashless does not mean without cash. It’s a benefit offered by the Insurance Company. Cashless doesn’t mean you don’t have to pay any amount. You have to pay charges for the items not covered in your policy and also proportionate charges if you get admitted to a HIGHER room category than your eligibility mentioned in your policy.
- Please ensure to check the list of hospitals before admission. If you get admitted to a non-preferred hospital, your claim will not be settled.
- Please ensure that the claim is intimated within 24 hrs of hospitalization, and the documents are submitted within 30 days from the date of discharge.