Home/ Money / Calculators/  For a smoother claims settlement process

Reasons for a health insurance claim being delayed or rejected altogether range from administrative delays by hospitals to poor documentation, further enquiries by the insurer or even poor understanding of a policy by the policyholder. But you can prevent the claims process from turning sour by arming yourself with proper knowledge of your health insurance policy and the process involved in making a claim. Further, you will need to proactively engage with the hospital and the insurer to avoid delays.

Mint Money gives you three handy solutions that will put you in greater control while making a claim.

Know your policy

There are many health insurance plans in the market, and choosing the right one is important. That is because medical expenses are constantly rising, and you need adequate health insurance to be able to meet them. Many buy health insurance because it offers tax deduction under section 80D of the Income-tax Act, 1961. But not all health insurance policies will cover your hospital costs. For that you need an indemnity policy, or what is commonly known as a mediclaim policy. This policy pays for your hospitalisation, and also covers expenses pre- and post-hospitalisation. It also covers listed day-care procedures. This is the health insurance policy that you need to get first. But before zeroing in on a policy, make sure you have gone through its features.

Look at Mint Mediclaim Ratings (https://bit.ly/1O6z3Hr ) to choose plans best suited for you.

Run through exclusions

Once you buy a health cover, looking at what is excluded is the next instinctive line of enquiry. See what medical procedures are excluded, as well as the waiting period of the policy. A waiting period is that time when the insurer will not admit a claim. There are three kinds of waiting periods in a policy.

The initial waiting period, which is typically for 1-3 months, apply when you buy the policy for the first time. Hospitalisation due to an ailment is typically not covered during this time, but due to an accident is covered. Then there is disease-specific waiting period of 1-2 years on certain ailments, such as hernia and cataract. Lastly there is the waiting period on pre-existing ailments. A pre-existing disease is defined as a condition, ailment or injury for which the insured had symptoms and was diagnosed or received medical treatment within four years before buying the policy. Most insurers will not cover pre-existing ailments or hospitalisation associated with it for at least the first four years. Some may have a lower waiting period. Other than exclusions, co-payment and sub-limit clauses are also important to note. A co-payment clause means that you pay a percentage of the claim amount, whereas sub-limits mean capping the liability of the insurer. For example, a 5% co-payment clause means that you will pay 5% of the claim amount and the insurer will pay the remainder up till the sum insured. Whereas sub-limit on say the room rent—it may get defined as a percentage of the sum insured or a category of room you are eligible for—means the insurer has capped the amount payable towards room rent charges.

Sub-limits may also apply to certain ailments. You need to be aware of the sub-limits on room rent because usually other medical expenses are associated to the type of room you take, so you could end up paying the difference for not only the room rent but all other medical costs.

“It is important to understand what is covered and what is not. We often find that policyholders make claims without going through the features of the policy, and are disappointed when claims are rejected or not paid for in full," said Sanjay Datta, chief-underwriting and claims, ICICI Lombard General Insurance Co. Ltd.

Know the procedure

Now that we have taken you through the important features of health insurance, let us look at the claims settlement process. In case of a planned hospitalisation, like a knee replacement surgery, the claims process is initiated before admission. For a cashless settlement, the process starts with getting pre-authorisation from the insurer. “Make sure that your neighbourhood hospital is in the network of insurer," said Anand Roy, joint executive director, sales and marketing, Star Health and Allied Insurance Co. Ltd. “Hospitalisation in a non-network hospital is through reimbursement which can be a long process. That is because with the network hospitals, insurers have a clear arrangement and understanding of medical procedures and costs, so claims are settled faster. With non-networked hospitals, the insurer will want to inspect and review every aspect of the claim," added Roy.

For cashless claims, you and your doctor need to fill up a pre-authorisation form. Pre-authorisation is merely an acknowledgment by the insurer that the claim is payable and is not a guarantee. You need to fill up personal and insurance policy details. “Once the details are provided by the patient, the pre-authorisation form is sent to the treating doctor for filling up the details of the ailment and treatment. The bill is then sent to the billing department to fill up the estimate as per the ward selected and the proposed treatment. The form is then signed by the treating doctor and the patient and is forwarded to the insurer along with necessary documents," said Anuj Gulati, managing director and chief executive officer, Religare Health Insurance Co. Ltd. “In an unplanned event, the process is same. But as the admission cannot wait for the insurer to authorise payment, the policyholder is asked for a deposit by the hospital that gets reimbursed later," he added.

This entire process can take up to a day, but many insurers now promise a quick turnaround of a couple of hours. “Due to the standardisation of claim forms and the list of non-payable items, a quick turnaround at the pre-authorisation stage is possible," said Datta. The actual time for the pre-authorisation will also depend on insurer’s review. “There could be instances in which the medical adjudicator of the insurer may want additional documents. This is then sent by the hospital to the insurer for review. Once accepted, the insurer will approve an initial amount as per the agreed tariff of the hospital," said Gulati. The policyholder is then admitted, and the treatment begins.

You or your family should know the approval amount so that if the hospital exceeds that amount, it can be sought from the insurer. “If the actual bill exceeds what is approved by the insurer, it could lead to further delays if this is brought up at the time of discharge, as the insurer will want to investigate the reason for additional charges. Keep the insurer informed as and when the charges exceed the approved amount," said Kapil Mehta, co-founder, SecureNow Insurance Broker Pvt. Ltd.

Make sure the paperwork is in order a day before the discharge. How smoothly your claims get settled will largely depend on the administrative efficiency of the hospital and the insurer.

“Check with your treating doctor for a probable date of discharge, also request for the time. Inform the insurance help desk and ask them to prepare the relevant documents so that they can be sent to the insurer immediately when the discharge is ordered," said Gulati.

But even in the best of hospitals, a wait time of 7-8 hours for claims approval and discharge is common. “We often find that the insurance help desk is unmotivated. So, you should get the documents in one place for the help desk to send to the insurer. Then you need to keep calling the insurer or the third-party administrator to check the status," said Mehta.

A proactive approach will make sure you are able to get your policy to pay for your hospitalisation quicker and easily to a large extent. Also, since a lot of times hospitalisations are unplanned and urgent, a good policy and prior knowledge of how things work will help make things that much smoother.

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Updated: 03 Jun 2016, 04:02 AM IST
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