INSUBCONTINENT EXCLUSIVE:
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
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
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.
