HEALTH INSURANCE - CLAIMS SETTLEMENT

What is cashless hospitalization?

Cashless hospitalization is service provided by an insurer wherein you are not required to settle the hospitalization expenses at the time of discharge from hospital. The settlement is done directly by the insurance company. However, prior approval is required from the TPA before the patient is admitted into the hospital.

What are the types of cashless claims?
Cashless claims can be of two types:-

Planned: Where the insured is aware of the hospitalisation 2-3 days in advance.

Emergency: Where the insured or any covered family member meets with sudden accident or suffers from bout of illness that requires immediate hospitalisation.

What do I do in case of planned / emergency hospitalisation?
In case of planned hospitalisation

·         Contact the toll free help-line number.

·         Fax / submit the required documents. E.g. Doctor’s certificate, etc.

·         Obtain approval from the TPA .

·         Obtain authorisation for network / non-network hospitals.

·         Avail health treatment.

In case of emergency hospitalisation

·         Rush the patient to the hospital

·         Patient avails treatment

·         Family contacts toll free number provided by the insurer

·         Family submits required documents. E.g. Doctor’s certificate, etc

·         Family obtains approval from the TPA

·         Family obtains authorization for network / non-network hospitals

·         Hospital bills are directly settled by the TPA

What is non-cashless claim or claim reimbursement? How do I go about filing such a claim?
A non-cashless claim is when you avail treatment in hospitals that do not form part of insurer’s network. In such cases, you have to pay the hospital bills and subsequently claim reimbursement from the insurer.

The procedure to be followed in case of claim reimbursement :-

·         Call toll free number and provide hospitalization details.

·         Settle the hospital bills directly.

·         Submit the relevant bills / documents to the TPA.

What are the documents required for filing a non-cashless claim?
The following documents are required:-

·         Duly completed claim form

·         Xerox copy of the policy

·         Bills, receipts and discharge certificate/card from the hospital in originals

·         Bills from chemists supported by proper prescription

·         Receipt and pathological test reports from a pathologist

·         Medical practitioner / surgeon prescribing the test.

·         Nature of operation performed and surgeon’s bill and receipt.

The claims are serviced at both network as well as non-network hospitals.

What are the dos and don’ts for cashless and non-cashless hospitalisation?

Cashless Hospitalisation
Dos

·         Intimate your TPA before admission to network hospital.

·         Ensure that you have ID Card at the time of admission to a hospital.

·         Provide complete information in prescribed format.

·         Carry necessary medical and investigation reports.

·         Register / reserve your admission as per the selected hospital’s procedure for admission

·         Admission at network hospital is subject to availability of bed.

·         Cashless facility is always subject to your policy terms and conditions.

Don’ts
Don’t claim the following expenses:-

·         Telephone \ Fax

·         Food & Beverages for relatives

·         Toiletries etc

·         Ambulance service (unless specified in the policy)

·         Don’t conceal or misrepresent any data at the time of buying a policy.

Non-cashless Hospitalisation

Dos
Forward all the relevant reports and documents in original to TPA for claim reimbursement.

Don’ts
In case of surgeon / consultants bills, insist on a stamped, preferably numbered receipt.

How can I prevent rejection of my claim?
You can stick to the following rules to prevent rejection of your claim:-

·         Read the list of coverage and exclusions in policy wordings (which comes to you with the policy).

·         Ensure that you declare all the pre-existing diseases at the time of enrolment.

·         Do not claim for any hospitalisation and diagnostic studies / investigation charges, which do not confirm existence of an illness or injury that requires hospitalisation.

·         After filing your claim, make sure that you maintain minutes of your interaction with the insurer in black and white.

·         Understand you policy in detail. Be informed about the ‘Fine print’ , exclusions and details pertaining to depreciation and deductions.

·         Do not hesitate to ask details of deductions or rejections.

Source: www.icicilombard.com