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What to Do If Your Health Insurance Claim is Delayed

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Overview

When it comes to paying for hospital stays or other related medical expenses, health insurance might be helpful. Comprehensive health insurance policies cover a variety of costs, including those related to prescription drugs, hospital stays, procedures, and doctor consultations.

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Key reasons why obtaining a health insurance policy is a good idea

Protect yourself from lifestyle diseases: Due to a sedentary lifestyle and increased stress, these diseases are becoming more prevalent in younger people, even though they were formerly more common in older adults. A comprehensive health insurance plan helps you pay for prescription costs and shields you from unexpected payments that may arise from routine testing.

Protection for the whole family: Health insurance companies provide all-inclusive policies that take care of everyone’s medical needs. In addition to protecting your family and allowing you to give them the best healthcare facilities, having comprehensive family health insurance can stand you in good favor in the event of any unfortunate events.

Protect yourself against medical inflation: Every day, there is a noticeable increase in inflation in all areas of goods and services. The cost of everything is constantly going up, from consultation fees to medications, hospital stays, and ambulance rides. Keeping up with inflation can be achieved by purchasing a comprehensive health insurance plan.

Protecting your savings: If you and your family do not have comprehensive health insurance and you become ill or are involved in an accident, you might have to use your hard-earned money and savings to pay for quality medical care. Insurance guarantees that in the event of a health emergency, your savings catastrophe.

Workings of Health Insurance Claims

The moment of truth for any insurance policy, but particularly for health insurance coverage, occurs when an insurance claim is filed. It’s critical to have a sufficient health insurance policy, but it’s also critical to comprehend the claims procedure so that you can rely on your insurance in an emergency.

Health insurance policies admit two types of claims:

  • Cashless claims
  • Reimbursements

Cashless claims

The fact that cashless claims are simple and easy to use is now their greatest advantage. The majority of insurance companies typically have partnerships with a network of hospitals, and you can take advantage of the cashless claim option when you select one of these hospitals for your care. You wouldn’t be required to pay anything in the event of a cashless claim because the insurance company will handle the settlement with the hospital directly. This implies that you won’t have to pay out of pocket for care received at any of the network hospitals because the insurance company will pay the bills immediately.

Reimbursement Claims

If you choose the reimbursement option, you will be required to pay the bills in full before the insurance provider processes your claim and reimburses you for the amount you spent, based on the original hospital bills. This will undoubtedly not go as smoothly as a cashless claim. You are not, however, limited to using network hospitals while seeking medical attention. You can select any hospital of your choice.

Why the Health Insurance Claim Gets Delayed

Delays in insurance claims might happen for a number of reasons. The following are some typical causes that may cause delays in the processing of insurance claims:

  • Erroneous or incomplete information: The insurance company may need to request further documentation or clarification if the information on the claim form is not complete or contains errors. This can lead to delays.
  • Absence of supporting documentation: Police reports, medical records, claim forms, and other types of evidence are frequently needed to substantiate claims. The claim procedure may be prolonged if certain documents are missing or need time to collect.
  • Investigation: If there are any suspicions of fraud or if the claim is large, insurance firms may be required to look into the circumstances surrounding it. This research may require some time.
  • High claim volume: Insurance firms may be inundated with claims during periods of high claim volume, such as following a natural disaster. Processing times could get longer as a result.
  • Underwriting review: In order to ascertain coverage and liability, certain claims must be reviewed by the underwriting department of the insurance company. The procedure can be slowed considerably by this extra step.
  • Administrative problems: Internal administrative problems in the insurance company, like incorrect data entry, misunderstandings, or misdirected claims, can also cause delays.

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What if your Health Insurance Reimbursement Claim gets Delayed?

As per IRDA Guidelines on Standardization of General Terms and Clauses in Health Insurance Policy Contracts Ref. No: IRDAI/HLT/REG/CIR/152/06/2020 dated 11/06/2020, Annexure 1, Point 3:

  1. The company shall either settle or reject a claim, as the case may be, within 30 days from the date of receipt of the last necessary document.
  2. In the case of delay in the payment of a claim, the company shall be liable to pay interest to the policyholder from the date of payment of the claim at a rate of 2% above the bank rate.

The insured has the option to expedite the claim in the following circumstances when a claim is delayed and the cause is unknown—even after all requirements are met and the procedure has been finished:

  • To determine the precise point at which the claim is blocked, you might consult your agent. Because the agents represent the insurance companies, they have a relationship with them and can therefore find out the current status of the claim.
  • Clients can log in on the companies/TPAs portal. Therefore, by going to their web portals, you can ascertain the current status of your claim, ascertain the cause of any delays, and determine a resolution. 
  • Consistently sending emails to the GROs and claims team, seeking updates to the concerned team. 
  • Maintaining continuous correspondence with persons engaged in the claims procedure, such as the surveyor, TPA, company, and investigator.
  • You may also raise a complaint on Bima Bharosa, the Grievance Redressal Mechanism integrated by IRDAI.
  • In case of no response or resolution, you can approach the Insurance Ombudsman.

Things to Keep in Mind While Raising A Health Insurance Claim

Medical emergencies are a serious concern, and in the heat of the moment, you could forget about the claims procedure. 

Here are a few things to keep in mind in these kinds of circumstances: 

  • Required documents: You must provide the pre-authorization form, the original medical records, a valid ID proof, bills for the tools and equipment used during the procedure, a canceled check, a copy of the policy plan, and any other documents requested by the service provider.
  • Recall that your chosen sum insured limit determines the validity of your health insurance claims. If your claim exceeds this amount, you will be responsible for the difference. It is advisable to verify the amount covered and select a policy that offers sufficient coverage.
  • Watch out for the exclusions: There may be a few exemptions from some health insurance policies that you should be aware of. Select your coverage carefully since you won’t be covered for the exemptions.
  • Keep in mind the deadlines for the claims procedure; failure to comply with them may cause processing delays and prevent you from using the cashless claims feature. 
  • In the event of an emergency, have a list of the partner hospitals available if you decide to go with the cashless claims option.
  • A lapsed policy will prevent you from being able to make claims, so make sure to renew your health insurance before it does.

Health insurance claim delayed

Conclusion

Policyholders should communicate effectively with their insurance carrier, promptly supply all required documentation, and submit complete and correct information to help speed up the claims process and prevent delays. It might also be useful to understand the terms and coverage of your insurance in order to avoid misconceptions that could cause delays. You can think about submitting a complaint or contacting your Insurance Company Branch for help if you encounter lengthy delays that you feel are unjustified.

By- Priyanshi Aggarwal

Also Read:  What is Critical Illness Cover in Health Insurance?

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