Master the claim procedure to cope better during emergency in family

At the time of writing, the total number of Covid-19 cases has crossed the 39-lakh mark globally and 56,000 in India. Expenses for the treatment of this disease can run high, especially if a person has to be hospitalised for a prolonged period or needs to be admitted into the intensive care unit (ICU). Factors like rising incidence of lifestyle diseases and high health care inflation have already sensitised educated Indians towards the need to buy adequate health insurance for themselves and their family. 

With the onset of this pandemic, policyholders should now take the next crucial step of understanding how to go about filing a health insurance claim. This will help them avoid last-minute hassles at the time of admission into a hospital, when they are likely to be burdened by worries about the health of a near one and want treatment to start at the earliest.

Health insurance can be claimed in two ways: cashless and reimbursement. Let us examine each one of them in detail.

How to make a cashless claim

Cashless claim facility is provided when the policyholder goes to one of his insurer's network hospitals for treatment. He is not required to shell out any money, except for non-medical items. The insurance company pays the cost of treatment directly to the hospital, provided the policy sum insured is adequate and the insurer meets all the terms and conditions of the policy. Cashless claim facility is available for both planned and unplanned medical emergencies.

Let us now turn to the procedure that the customer needs to follow to avail the benefit of cashless claim. If it is a planned admission, he should approach the hospital's insurance desk for guidance on availing the cashless facility. The insurance desk will forward the customer's pre-authorisation application form and his entire case to the insurer. If some of the documents required by the insurer for making the decision are missing, it will ask the insured to submit them. Depending on the details of the case and the policy terms and conditions, the insurer will approve the cashless facility. Ideally, this approval should be taken four-seven days prior to admission.

Customers usually need to produce the following documents at the network hospital: pre-authorisation letter (completed by the insurance desk); ID card issued by the insurance company; health insurance policy; Aadhaar card, PAN card or Form 60 (for KYC purpose). They may have to submit some additional documents as well if required by the insurer.

Once the treatment is done and the customer has availed of the cashless facility, he should leave the original bills and other evidence of treatment with the hospital. The hospital shares them with the insurance company after which the latter processes the payment to the former.

In case an unplanned or emergency medical treatment is required, the policyholder should contact the insurer's customer care centre or chat bot facility to learn about the empanelled hospitals close to his home. Once the customer reaches the hospital, he should request for cashless hospitalisation by producing his insurance card and submitting a copy of his health insurance policy at the insurance desk.

Again, the hospital will connect with the insurance company by filing the pre-authorisation request form. The insurer will then issue an authorisation letter to the hospital. The insurer will also share details pertaining to the customer's policy coverage. Once the treatment is over, the insurer will settle the payment of admissible claims with the hospital.

Sometimes, the insurer is unable to accept the liability on the basis of the information provided at the cashless stage. The customer is then asked to put up his case for reimbursement.
 

Selecting a health insurance policy? Look at these factors

• Check out the period for which pre-existing diseases will not be covered
• This period can range from two to four years. Lower is better
• Find out whether the policy has a co-payment clause
• If the co-payment requirement is, say, 20 per cent, you will have to meet this portion of the bill out of your own pocket
• Make sure that the policy comes without sub-limits
• If there is a sub-limit of 1% on room rent and the sum insured is Rs 5 lakh, you will not be allowed to stay in a room that costs more than Rs 5,000/night

How to file for reimbursement 

Besides cashless, the other way customers can settle their health insurance claim is via the reimbursement mode. Customers usually have to opt for this mode when they select a hospital that suits their needs, or whose location is more convenient for them, but is not empanelled with the insurer. In such a scenario, the policyholder has to foot the entire medical bill himself. Later on, once the treatment is over, he can file a claim for reimbursement. Let us now turn to the procedure for filing a reimbursement claim.

The insured first needs to download the claim form from the insurance company's website. He can also collect it from any of the offices of the insurer or from an intermediary. He needs to provide the necessary documents and the original medical bills while filing his claim. The documents that are typically required include the claim form, bank details, ID card, hospital discharge summary, investigation and diagnosis reports and bills, original hospital and pharmacy bills, and paid receipts and prescriptions. In case of accidental hospitalisation, the customer will also have to share a copy of the first information report (FIR) with the insurer.

The insurance company evaluates the claim on the basis of the documents provided by the insured. It also ensures that the policyholder meets the terms and conditions of the policy. If all is in order, then once the evaluation is complete the insurance company makes a pay-out to the beneficiary. If the insurer fails to provide certain mandatory documents, the insurer may once again ask for them and only then decide on the claim. If the claim gets repudiated, the insurer will provide the reasons for its decision.

Choose the right insurer

Finally, when buying a health insurance product, one should not go solely by the premium. Instead, one should also try to understand the policy features and then select one that provides comprehensive coverage to the family. Make sure that the list of empanelled hospitals of the insurer includes some of the top-quality ones in your vicinity — those you are most likely to visit in the event of a health emergency. Also, try to develop a detailed understanding of the exclusions (what is not covered) in your policy. It will ensure that you have a fair idea of the circumstances in which your claim could be repudiated. This way you will not have a wrong set of expectations and will be able to avoid an unpleasant surprise at the moment of truth.

The writer is chief technical officer, Bajaj Allianz General Insurance