If you are shopping for health insurance, you can either opt for a cashless policy or go for a reimbursement claim. It is important to understand the claim procedure laid down by insurers.
• Insurers have tie-ups with a network of hospitals across the country. If you opt for cashless claims, you can avail of cashless treatment at those hospitals. The network list is available in the policy kit and also on the insurers’ websites.
• In case of emergency hospitalization and admission, the TPA (third party administrator) should be intimated within 24 hours. But in the case of a planned admission, the TPA must be informed three days in advance.
• Fill up the cashless request form and get it certified by the doctor.
• Fax the form, with supporting medical records, to the TPA’s fax number.
• On scrutinizing the documents, the TPA conveys the decision to the hospital for sanction of the cashless request or calls for additional documents if required.
• On approval of the cashless facility, the hospital bill is settled directly by the insurer (subject to policy limits). Inadmissible amounts such as telephone, food and attendant charges are to be borne by you.
• If you choose to go to a hospital which is not part of the network, you can still get reimbursement directly from the insurer.
Reimbursement of claim
This facility is available at network as well as non-network hospitals. You can avail of treatment, settle all bills with the hospital and file a claim for reimbursement. You must intimate the insurer within seven days of the date of discharge. The policy certificate number should be quoted and the claim can also be intimated online through the company website. You need to submit the following documents (originals) to the insurer within 30 days of the date of discharge:
• Duly filled claim form along with the doctor’s certificate (forming part of the form)
• Discharge summary
• Bills and receipts (including advance and final receipts)
• Prescriptions for medicines and doctor’s advice for laboratory tests
• Diagnostic test reports, X-ray, scan and other films
The claims will be processed on receipt of all the documents and additional material. Information will be called for after claim scrutiny if required. The cheque will be sent to the customer if the claim is admissible. If not, a repudiation letter explaining the reasons for the rejection of the claim will be sent.
Dos and don’ts
For cashless claims:
• Always carry the health card which gives you the unique membership number that is used by the TPA to identify you and provide the cashless benefit.
For reimbursement claims:
• Always insist on getting the original discharge summary and reports from the hospital.
• Keep copies of lab reports for future medical follow-ups.
• Always retain copies of all claim documents before submitting them to the insurance company (in the event of the documents getting lost in transit).
• Insist on getting properly numbered, stamped, signed and sealed receipts from the hospital/physician for any payments made.
• Preserve the prescriptions given by doctors for medicines and lab tests; these need to be submitted along with other claim documents.
• For all traffic accidents, ensure that a complaint is lodged with the police and get a copy of the FIR.
A common myth among customers is that insurers always reject claims. There are times when the claim will be rejected by the insurer—for instance, if the illness is not covered by the policy. In such cases, the customer should not look upon the “premium paid as premium lost” or, in other words, as an investment on which he has not got returns, and subsequently fail to renew his policy. Illnesses keep occurring and the next time you fall sick, the disease in question may be in the list of inclusions. In such a case, if your policy hasn’t been renewed, you will be the loser.
(Ajay Bimbhet is managing director of Royal Sundaram Alliance Insurance Co. Ltd)
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