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Last Modified: Mon, Feb 26 2018. 01 12 AM IST

Pre-approval does not mean quick claim settlement

It’s important to know that when an insurer promises quick approval of claims, it may not mean that you will also be able to walk out of the hospital with all your bills paid by the insurer in no time

Photo: Ramesh Pathania/Mint
Deepti Bhaskaran

A cashless health insurance policy settles your claim directly with the hospital, so that you don’t have to pay the bills from your pocket at the time of discharge. But this is a layered process and can take some time. Yet, insurers also boast of quick claims approval time. Both statements can be true. Read on to know how. 

Approval

For a cashless settlement in health insurance, the process of making a claim starts with getting pre-authorisation from the insurer. This is merely an acknowledgment by the insurer that the claim is payable. It is not a guarantee that the claim will be cleared. You and the treating doctor need to fill the pre-authorisation form. You need to fill the personal and insurance policy details. Then the form is sent to your doctor for filling in details of the ailment and treatment. The form is then sent to the billing department to give an estimate and then it is sent to the insurer, with the necessary documents.

The insurer reviews these documents to pre-authorise the claim. And this is where the insurers boast of a quick turnaround time. But keep in mind that the insurer may still ask for additional documents in order to approve the claim, and that could take time. 

Pre-authorization approvals usually mean that an initial amount has been sanctioned by the insurer along with admitting to paying the claim subject to the final invoice from the hospital. So it’s at the time of discharge that the insurer actually pays. Non-payables will have to be paid by you. Read more about it here. In some cases, hospitals may demand a deposit—especially in cases of unplanned events where admission cannot wait for pre-authorisation from insurers.

Final settlement

Pre-authorization has now become a quick process, but claims settlement at the time of discharge can still be a lengthy process. For instance, in order to process the claim, an insurer will need the discharge summary, which itself can be a long process. Once the discharge summary and hospital bills are sent to the insurer, it will scrutinise the bills before settling them. And this may take time because the final claim undergoes several levels of scrutiny. For you, this means a long wait before you can finally leave the hospital.

It’s important to know that when an insurer promises quick approval of claims, it may not mean that you will also be able to walk out of the hospital with all your bills paid by the insurer in no time. It simply means a quick turnaround on whether the insurer has agreed to accept the claim. The final claim is still subject to adjudication by the insurer.

Topics: health insurance1 hour approval

First Published: Mon, Feb 26 2018. 12 45 AM IST

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