In a day-to-day life so many times we find people who are complaining about insurance companies. All the hassles and paper-work to be done and yet at times the claims are unsettled for various reasons.
Many of us buy health policies in March to get tax advantage and many buy it to oblige their friends and relatives who are ‘agents’.
There is very little awareness about the advantages of health insurance Very few realize the importance of a health insurance policy and have the knowledge of how a health policy can work to one’s advantage. Knowing and understanding the product is only half-cooked food.
It is also apparent to know the claim and settlement process. It is required to understand the role of the TPAs, documents that may be needed, policy documents, cashless card etc.
For better understanding of the processes, few quick tips are mentioned
A) Hospitalization in Network Hospitals
Every insurance company has a list of paneled hospitals across India. Cashless hospitalization can be availed at any of the hospitals in the panel.
For Availing the Cashless facility at these hospitals, one has to go through the TPA (Third Party Administrator).
It is the TPA that will authorize “Cashless Service” at the empaneled hospitals in all cases eligible under the insurance policy.
- As soon as possible inform your TPA (The contact number for the TPA will be mentioned in the policy or available on the respective insurer’s website) and coordinate with the hospital to have the details sent to TPA for authorization of cashless service.
- On discharge, verify and sign the bills and pay for the items that are not payable under the health policy (Policy document contains all the details about the expenses covered & not covered).
- The original discharge summary and other investigation reports should be handed over to the hospital. Please retain a photocopy for your records.
- In case of a planned hospitalization, kindly coordinate with the hospital and send in all the details of your hospitalization at least 3 days prior to the admission, including the plan of treatment, cost estimates etc. to TPA. Also indicate the contact details of the hospital to send the authorization.
B) Hospitalization in Non – Network Hospitals
As soon as possible, inform TPA about the hospitalization. At the time of discharge, settle the hospital bills in full and collect all the bills, documents and reports. Register your claim with TPA for processing and reimbursement.
How to lodge your claim with TPA for processing and reimbursement?
Please register your claim with TPA within 7 days of discharge. Kindly send the documents listed below for processing your claim:
- Duly signed claim form
- Identity proof
- Copy of Policy Document
- All hospital bills in original with detailed breakup for consolidated amounts
- Bills for medicines purchased from outside, should be accompanied with a doctor’s prescription
- Discharge summary / Discharge card in original
- All investigation reports in original
Documents in addition to those mentioned above may be called for depending on the nature of claim lodged. Please retain a copy of the documents sent for your records.
Most importantly, the delay in intimation of claim may lead to rejection of claim.
If above is taken care then one can be assured that he will not have to face much hassles during his/her claim settlement.
Curated from Make your health insurance claims hassle free