You have bought a good health insurance cover, but you also need to be good at knowing how to claim the insurance money, should a need arise
According to the rules on claims settlement for a health insurance policy, the insurer has to take a decision to pay or reject a claim within 30 days. The 30-day window starts from the time the insurer receives the last necessary document. So, what are these documents? We asked insurers and brokers and compiled the list for you. Read on.
If you make a cashless claim (hospital settles bills directly with insurer), there isn’t much you need to do as your hospital will handle the process of submitting relevant documents. You can, however,ensure that all the paperwork is in order a day before discharge.
In the case of reimbursement claims, where you pay the hospital bills directly and then get them reimbursed by the insurer, make sure you have all the necessary documents.The insurer will need the claims acknowledgment number. This is the number the insurer gives you when you walk into a hospital and inform the insurer that you would be making a claim. You also need to fill a claim form and send a list of medical documents—discharge summary, diagnostic tests and reports, their bills, treatment charges and doctor’s prescription. You will need to give a cancelled cheque and fill up an electronic clearance service (ECS) form so that the insurer can transfer the money into your account.
Do remember that the policy also covers pre- and post-hospitalisation expenses. So even if hospitalisation expenses are covered in a cashless way, expenses on pre- and post-hospitalisation are typically reimbursed.
Most policies cover medical costs up to 30 days before hospitalisation and about 60 days after it.
Two things are important for the insurer: duration of pre- and post-hospitalisation expenses and if the expenses were incurred for the medical condition for which you got hospitalised.
Duration of claim settlement
To make the claim process easier, the rules clearly state that apart from the list of necessary documents, no other documents are required to settle or reject a claim, unless, of course, the insurer suspects fraud. And the insurer has to ask for all documents at one go.
The rules also state that all the information related to the insured and the medical history captured at the time of selling the policy should be held in electronic form. Same goes for earlier claims. This is so that the insurer doesn’t need more details from you when a claim is made.
The insurer can tell you by when all necessary claim documents need to be submitted. If there are valid reasons for a delay, the insurer has to consider the claim.
But the real challenge that reimbursement claims still face is final settlement of the bill amount, when the money comes into your account. According to an insurance broker we spoke to, this could take up to 10 days for private insurers and a couple of months with public sector companies.
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