Purpose of Health insurance is to avail monetary support during period of treatment in hospital. Health insurance is an indemnity product which means that Insurance Company indemnifies the monetary expenses incurred on account of medical treatment. It also means that insured cannot take any gain out of such arrangement. Health Insurance Claim can be availed through cashless arrangement and/or through reimbursement. Cashless is a smooth system where Insurance Company directly pays to the hospital without any monetary pressure to the family of insured. In case cashless claim is not approved or treatment is not taken in Network hospital then claim can be taken through reimbursement.
How to file reimbursement claim for health insurance cover
A reimbursement system can be more customer friendly as per reasons below :
- There is no need to look around a network hospital and policy holder can go to a hospital of choice.
- Better negotiated control on expenses because policy holder has to bear all expenses. Room selection is done with budget in mind.
- Policy holder can verify all papers before sending and correct any discrepancy.
To understand reimbursement claim, insured need to remember five critical points:
5 Critical points to remember filing health insurance reimbursement claim
- Insurance Company must be informed about the admission in a hospital within 72 hours and medical bills should be sent or uploaded within 30 days of discharge from Hospital.
- Maintain a file of all expenses related to treatment. Ask question if any expense is not clear. Check any remark which is contradicting to standard protocol of treatment. Raj was admitted for treatment of Hernia. He developed headache and advised a MRI and visit of Neurologist. Neurologist made a remark that patient had a history of headache for 3 years. Claim was rejected on the basis of non-disclosure of pre-existing disease. Such incidents happen quite frequently and claims are rejected. Hence it is imperative that policy holder check and seek clarification.
- Insurance Company would need signed and stamped documents as given below :
- Reimbursement Form as downloaded from the website or collected from office of insurance company.
- Discharge Summary
- Bills of all procedures
- Medicine Bills
All bills need to be given a serial number and with an explanation note wherever required for early reimbursement. Please note that most short settlement or rejection happen because of poor documentation
- Policyholder also need to send Policy document or Medical Card. Besides Medical card, Insurance Company also seek ID card like Aadhar card, Doctor recommendation for hospitalization, supporting medical papers justifying hospitalization.
- Policy holder must take note of Policy terms and conditions as per list below:
- Limits on certain procedure for example Cataract.
- Room rent capping like 1% of sum assured. Please note that all hospital expenses are governed by room rent. A Doctor visit charge will be different for Deluxe room and for a Twin sharing room.
- Waiting period for certain diseases
- Co Pay in which Policy holder has agreed to bear a percentage of expenses.
Exclusions under Health Insurance Claim
Scope of Reimbursement claim: almost all type of treatment and related expenses can be covered under reimbursement. Given below is the list of expenses which can be covered under reimbursement claim:
- Ambulance charges.
- Pre and Post Hospitalisation
- Treatment under day care – specially planned surgeries when authorization is taken 48 hours in advance.
- All major surgeries including Dialysis/Chemo unless categorized under exclusions in the Policy document. Insured should refer the Policy Document for exclusions.
Precautions for reimbursement claim:
- Choose a hospital and select a room as per your budget. Please visit website of Insurance company and ensure that hospital is not black listed
- Ensure that Hospitalisation is required and it is not done for examination purpose. Ensure that attending Doctor is making a diagnosis and recommending Hospitalisation under a standard treatment protocol.
- Study the Admission papers and read words like KCO (Known case of) and discuss with attending Doctor. Most claims are rejected on grounds of Pre-Existing disease and mention of KCO indicates that patient had history of disease. During COVID, Mohan was admitted post RTPCR and difficulty in breathing. Family of Mohan mentioned that Mohan had been hypertensive and admitting Doctor mentioned KCO HTN, which means that Mohan was a patient of Hyper tension. The fact remains that Mohan was never diagnosed with Hyper Tension and was never advised any treatment. Mohan only showed symptoms but was not diagnosed. During emergency, family members truthfully declare all symptoms but do not explain that patient has not been diagnosed. Most of claims are rejected by sheer mention of KCO. It is advised that family tell the history of only diagnosed diseases and not casual symptoms.
- Always maintain a file of all documents sent to Insurance Company. They demand all documents in original hence you need to keep a copy of all documents with serial number.
In case of any problem, you can always take help of Insurance Desk of Hospital.