It is very important to know the claim settlement procedure preferably before signing up for the policy. This information is printed well in the brochure or you can contact the insurance company help desk for exact details. The claim procedure remains unchanged no matter what type of health insurance cover is bought i.e. either individual or family floater. These days, majority of the Insurance Companies have set up a 24/7 help desk service for the assistance of customers.
2 Types of claim health expenses procedure
1. Reimbursement Claims
Insurance Company is notified of the need of hospitalization is intimated and the insured is taken to either any hospital or one of the hospitals from the insurance company’s network. All the expenses are paid by the insured initially and then all such bills are presented along with the claim form to the insurance company for a reimbursement.
The standard procedure is
- To intimate the insurance company help desk as soon as the need for hospitalization arises
- Any family member or friend can make this intimation in case the insured cannot do this formality
- Information of policy number, Name of insured, Contact Number, Name of Sickness and the date since the symptoms of such sickness were noted and the need for hospitalization
- If hospitalization is due to accident, then the time, location and date of such accident needs to be disclosed
So, if there are 4 members in a family and each of the members has a separate health insurance cover. It is suggested that one document is prepared where in health insurance policy number, name of insurance company, sum assured, help desk number and other such details are noted. Make sure all the family members are aware where this document is placed so that they can manage things well at the time of emergencies.
2. Cashless Claims
This facility is provided by majority of the insurance companies wherein if the hospitalization happens in one of the hospitals from the network of different hospitals, the insured doesn’t pay for the medical expenses either at the time of admission or at the time of discharge, they are taken care of through the cashless facility between the hospital and the health insurance company.
A separate form is to be filled for requesting cashless facility at the time of admission at the network hospital. This request form is then taken up to the TPA for approval by the hospital. Insured needs to attach the medical insurance card that is issued by the insurance company along with a photo ID at the time of making such request. Approval of such requests rests at the discretion of the TPA, it may be denied under the following conditions
- If the information detailed in the request form is insufficient
- The ailment/condition (sickness) is not covered under the health insurance policy
- If the request of pre-authorization is sent at a short notice
- In case the TPA wants to get more information from the health insurance company regarding the sickness/condition that needs to be treated
- It’s better to wait for the approval before getting admitted to be assured, if the facility is made available or not.
If in the case where cashless facility is denied, the insured can still get treated for the sickness and manual claims can be sent to the health insurance company at a later stage. In the case where hospitalization is done in Emergency then the health insurance company needs to be notified at the earliest to avoid any complication at the time of making claim.
Domiciliary Hospitalization means medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a Hospital/Nursing Home but actually taken whilst confined at home in India under any of the following circumstances, namely
- The condition of the patient is such that he/she cannot be removed to the Hospital/Nursing Home or
- The patient cannot be removed to Hospital/Nursing Home for lack of accommodation therein
For smooth claim process, just take care that all your documents are in place and to be on a safer side have a report from your family doctor, stating that this person cannot move to nursing home/hospital due to such and such reasons. It just provides the proof and makes the process simpler. Note that every company does not offer this facility; you should check your policy document.