Claiming Reimbursements For Health Insurance

If you do not have cashless cover for hospitalisation and medical procedures, you will need to submit your claim separately to get reimbursed for your expenses. There is no such thing as too much documentation to ensure a smooth claim reimbursement process, says Jay Sampat

There are many cases of Mediclaim policyholders having to claim reimbursement from their insurance companies for hospitalisation expenses, as a large number of hospitals have been removed from the list of network hospitals by PSU insurance companies. Moreover, most government-owned insurance companies (and some private companies) require you to deal with a third-party administrator (TPA) to make your claim, adding one more layer in the process. At the best of times, it takes at least two-four weeks for the claim to be settled. Let’s start by understanding the various ways to ease the claims process.

When you are diagnosed with an illness and are likely to make a claim, intimate your insurer on the helpline number that comes along with the policy. Also make it a point to have written communication via fax or e-mail. This intimation should mention your policy number and illness and should be in the prescribed format.

Subsequently, the insurance company or its TPA will get in touch with you, and you will be guided to a network hospital. TPAs will also tell you about the terms and conditions of the policy, the insurance cap if any for your ailment, and any restrictions in case you have missed the fine print. In case of an emergency hospitalisation in a non-network hospital, insurance companies allow 24 hours for you to inform them (network hospitals inform TPAs themselves).

Even getting admitted to a network hospital does not necessarily mean that the procedure will be cashless. Many renowned hospitals that are a part of an insurance company's network may still require you to pay in cash (and get reimbursed later) if your case is complicated or there is a chance of pre-existing illness. Moreover, many public sector insurance companies do not offer a 100 per cent cashless facility. Generally, customers face much more problems when it comes to making a claim after being treated in a non-network hospital.

Typically, inadequate documentation results in situations where the entire claim or a part thereof is rejected and customers end up blaming insurance companies and agents. For a smooth settlement, the smallest of details need to be taken care of. Important points to remember in the documentation process are:

a) In case of a non-network hospital, the insurance company will require a copy of the hospital's registration certificate when you submit the documents for a claim. Make sure to enclose this.

b) Each bill, whether medical or investigation (tests), needs to have supporting evidence. The insurer requires the original copy of the test result, the doctor's slip asking you to conduct the test and the invoice of payment made. For instance, if you are planning to make a maternity claim under group health company cover, keep all the reports including those for sonography, etc. All original bills and test reports need to be submitted to the TPA within seven days of discharge.

c) Each bill should carry the name of the patient as well as the doctor’s name. The same goes for investigation reports. If both the requisites are not fulfilled, the insurance company may reject the bills and the reports.

d) The name of the patient should be mentioned on the bills in the same spelling as provided in the insurance policy documents.

e) All insurance companies require an original copy of the discharge certificate. Moreover, the details provided in the discharge certificate should be uniform all across.

f) Insurance companies require the bills to come with sub-heads. This is necessary as insurers have a cap on some expenses. For instance, many insurance companies restrict the room charges per day to one per cent of the insured amount, while many PSU companies such as National Insurance Company allow for only 20 per cent of the sum assured as doctor's fee and up to 50 per cent for medicines.

g) While submitting the final bills, make a covering letter and attach a copy of the policy alongwith. It should also have a doctor's note describing the illness. Also, include a copy of the insurance card and a pre-authorisation request from the TPA if possible. Make sure to take an acknowledgement that the TPA has received the bills.

i) In case of post-hospitalisation charges, make a note of it in the claim and ask the TPA for the time limit to submit the documents.

Enrolling for an insurance policy doesn’t mean that you are absolved of all responsibilities. It is in your own interest to keep tabs on the rough bill that is furnished to you everyday. After all, each policy has a finite sum assured and you will need to foot the additional amount. Moreover, it makes practical senses to try and save on the bills as much as possible as the insured may face another emergency during the year.