A health insurance plan has two types of claim settlement processes: cashless and reimbursement.Health insurance, a type of insurance that covers cost of medical care, has become an imperative aspect of life today.
Just like car insurance, home insurance or any other type of insurance, in health insurance plans, customer chooses a policy and agrees to pay a certain cost - also known as premium - at regular intervals.
In return, health insurer agrees to pay at least a portion of eligible medical expenses incurred in a year subject to certain conditions.
At time of need, policyholder needs to put in a formal request to health insurance company to get benefits of policy.
This formal request or application is commonly known as claim.
The insurance company, thereafter, validates claim and, once approved, issues payment to insured or an approved interested party on behalf of insured.Types of health insurance claimsA health insurance plan has two types of claim settlement processes: cashless and reimbursement.Cashless claims: In case of a cashless claim, insurer settles all hospitalisation bills and medical expenses with hospital directly.
In other words, policyholder is not required to first bear expenses from own pocket until he or she is compensated for same by insurer.Reimbursement claims: In this case, health insurance claims process starts when a healthcare provider treats a patient and sends a bill of services provided to a designated payer, which is usually a health insurance company.
The policyholder has to initially make payments against medical bills on from own pocket.
Once insured gets treatment, insurer is then required to submit relevant bills to insurance company.
The company then reimburses medical costs incurred.
One can get reimbursement facility at both network and non-network hospitals.Here are some of factors that can impact your claims made against a health insurance plan:Sum insured: There is a certain insured sum involved when an individual opts for a health insurance policy.
Sum insured is maximum value for a year that health insurance company can pay as part of an active insurance policy.
This means that a claim on a health insurance policy can only be approved if it falls in sum insured limit.
In case policyholder utilises entire sum for a particular year, any additional cashless claims for that year get rejected.
Therefore, it is always advisable to have a sum insured of a large amount, say experts.
However, this would also lead to a higher premium.Specific coverage: Many health insurance plans available in market may have a specific coverage and there may be several diseases not covered under policy.
These are clearly mentioned in policy documents.
Before purchasing a health insurance plan, policyholder must read fine-print carefully to avoid confusion at time of filing a claim.
Filing a cashless claim for a disease or medical condition not covered under a health insurance plan leads to rejection.Representation of facts: Representation of facts is another important factor to be considered while filing a claim on a health insurance policy.
Coverage is provided on basis of information submitted by policyholder on proposal form; any mismatch between declaration and reality during time of filing claims can lead to rejection.
At time of buying a policy, policyholder must provide complete and accurate information.
He or she must not hide any medical history from insurer.
The name of patient and doctor should be entered correctly when filing a claim, otherwise it may lead to unnecessary hassles.
Also, documents - such as hospital bills, reports and prescriptions - should have correct information to increase chances of a quick and hassle-free claim settlement.Time limit: In a health insurance policy, policyholder is required to apply for reimbursement within a certain period of time.
If claim is not filed within specified time, claim is turned down.
To avoid rejection of claim, it is important to submit claim in time.Record of documents: At time of filing a claim, it is also advisable to maintain a record of all documents: pre- and post-hospitalisation expenses, hospitalisation records, diagnostic tests, discharge summary, investigation reports etc.
These documents can be extremely crucial in case insurer demands any clarifications.Policy number, contact details of insured, relationship of insured with person who is hospitalised, name of hospital, nature of ailment or accident and commencement date of symptom of ailment, among other details, should also be ready while intimating a claim, say experts.
These details assist insurance companies in processing claims and help rule out possibility of fraudulent and false claims for them.Premium payments: Insurance companies can deny claims in case responsible party has not paid monthly premiums.
If policyholder misses even one payment, insurer can suspend customer's policy.A health insurance claim protects an individual from prospect of large financial burdens resulting from an accident or illness.
Hence, policyholder should have a good understanding of health insurance policy, ideally from time of its purchase in order to avert any kind of confusion at time of filing a claim.
With this, policyholder is also guaranteed of a more secure future both health-wise and money-wise.Companies such as IFFCO Tokio offer a host of insurance policies.
Family Health Protector Policy, Individual Health Protector Policy, Health Protector Plus Policy Coverage are some of health insurance policies offered by them.