Manju Dhingra is an elderly lady and senior citizen whose only relative is her son. After her son moved to the US for better career prospects, she has challenges with managing many tasks. Her son is also worried about his mother and has recently got her one of the best medical insurance policies. She had gone to a hospital a few days ago and was diagnosed with appendicitis. Her appendix had to be surgically removed in an emergency procedure and thankfully the operation went well. Manju and her son are now wondering how to claim health insurance for these expenses.
A medical insurance claim or health insurance claim is basically a request that the policyholder raises for the expenses incurred in the medical treatment. As the request is raised, the insurance provider verifies the claim and either settle the medical bills with the hospital or asks the policyholder to pay it from their pocket and later reimburses the amount to the insured. It totally depends upon the type of health insurance claim process that the policyholder has chosen. This writing will help many policyholders in answering the important question of, how to claim medical insurance.
What are the types of medical insurance claims?
The main objective of any health insurance or medical claim policy is to provide financial support to the policyholders when needed. However, to get the coverage benefit from the insurer, the policyholders have to get either of the two services, which include:
In a cashless claim, the insured can get the required treatment at any network hospital of the insurance provider. While getting hospitalized, the insured must show his/her cashless health card that was provided to them by the insurance company. The bill raised by the hospital will be directly settled by the insurer. There is no need for the policyholder to pay even a single penny. You need to know that the majority of the insurance providers approve cashless treatment within four hours of admission at the network hospital.
Cashless claim settlement is available in two ways. And those are mentioned herein below:
- You have to choose a hospital from the list of network hospitals which is mentioned in the insurance document
- You would be required to inform the Third-Party Administrator (TPA) at least three days before being admitted to the hospital and provide a membership number
- You will then have to fill out a cashless request form which you will find at the hospital
- Now at the TPA counter, you have to submit the form as well as medical records
- All the submitted documents will be inspected by TPA
- Once all the documents are approved, the hospital bills will be settled by the insurance company. However, the only things that you have to pay for are attendant charges, phone charges, food, etc.
- If in any case, TPA does not approve it, you can file for reimbursement.
- If it is an emergency admission, you can inform the Third-Party Administrator and provide them with a membership number
- You have to then fill in the cashless form at the hospital, which has to be certified by a doctor
- Now send the form as well as the medical records to the TPA
- If the TPA sanctions the cashless facility, the insurance provider will directly settle the bills
- If it is not approved, you can look for reimbursement
For reimbursement, you would be required to pay for the treatment from your pocket, and then you have to file a claim for the reimbursement from the insurance company. As you try to claim, you have to submit the bills and also showcase the other records of the funds that were needed for hospitalization as well as the treatment. The insurance company verifies all the submitted bills and then credits the amount to the bank account of the policyholder.
If in case your cashless claim request is rejected somehow, or any of your family members is getting treatment at a non-network hospital, you can apply for a reimbursement. However, make sure that you apply for it within seven days of the discharge of the patient. Here are the medical insurance claims processing steps that you have to follow.
- You first have to contact the insurance company from which you have bought your health insurance policy. You can call on the toll-free number and provide your membership number
- After you have settled all the medical bills, you have to submit your bills, discharge summary, prescriptions, and other important documents that you want to be reimbursed
- You then have to download and fill out the reimbursement form that is available on the website of your insurance provider
- Now you have to submit the form as well as the medical records to your insurer
- As the claim is approved, they will disburse a cheque. The usual time taken for the process is 20 days from the date of receiving the documents.
While you are doing all these, make sure the form is duly filled. And in case you find any hindrance in the process, you can get in touch with Insurance Samadhan at your convenience. You can also refer to the sample letter to an insurance company for medical claims to make sure that you follow the right format and include all relevant details.