Claim in Health insurance

Methods to take successful claim in Health Insurance

These days people think that the claiming process in Health insurance is monotonous and devious so they avoid taking any insurance plan. Most of them think that there are too many restrictions with the coverage and they will have to pay from their pocket if they are going to make any claim. So instead of taking insurance they prefer to pay the entire hospital bill all alone. But this consideration is a complete myth. In fact, if you choose a correct health insurance plan then you don’t have to pay anything from your pocket at the time of making a claim. All you have to do is select the appropriate plan and leave all your dread behind. Sometimes the hassle in the claiming process caused the stiffness in the insurance plan but if you have selected for the apt plan then it will help you all your life.

Making a successful claim in Health insurance is the terrifying part of taking it. If you have never taken a claim on your insurance plan then you may never be able to understand the complexity of these plans. Sometimes these hassles in claiming are caused due to misunderstanding by customers, but most of the time it arises due to unfortunate cases. You can make a claim in two different ways under health insurance.

Types of claiming procedures in Health Insurance: You can pay the medical bills in two ways as per your convenience but the best way is a cashless settlement.

Cashless settlement: To get the cashless settlement facility you have to go to a nearby network hospital. The TPA of the hospital will directly settle the claim by contacting the insurance company without involving you. In this settlement either you have to pay some portion of money or the entire money will be paid by the insurance provider at the time of discharge. The only condition to avail this settlement is to take the treatment in the network hospitals of the insurance provider. Every preferred hospital has its third party administrator available in the hospital who will help you to complete the successful claim.

Claiming procedure for cashless settlement:

  • First of all, if you want to get admitted in a hospital due to your health conditions then you have to intimate the insurance company 2-3 days before admitting. In case of an unexpected medical emergency, you have to intimate at least 24 hours prior to admitting the patient.
  • After admitting to the hospital, you have to contact TPA as they will coordinate with the insurance company on your behalf and take care of your medical expenses.
  • Once the documents are given to the insurance company they will look after the terms and conditions of the policy and take consideration of the coverage amount.
  • The insurance company will thoroughly investigate the case and will inform the decision taken by them to the policy holder.
  • If the cashless treatment is possible then you can pay the medical expenses by the cashless card provided by the insurance company otherwise you have to pay the bills from your pocket and further can apply for reimbursement.

Manual Reimbursement of Medical expenses: If in case there is no preferred provider network hospital available near your residential area then you will make a move to admit the patient in the nearby hospital immediately. As this is a non-network hospital so you have to pay the entire amount from your pocket but you can reimburse it later by submitting the documents to the insurance company. Most of the people will not prefer this type because they don’t have so much money at times to pay on the medical bills.

Claiming procedure for Manual Reimbursement:

  • In this condition also, you have to inform the insurance company to complete the reimbursement process successfully.
  • Keep all the medical bills safely with the date mentioned on it.
  • After the complete treatment when the patient gets discharged from the hospital, contact the TPA of the insurance provider to hand over the bills to the insurance company and start the process of reimbursement.
  • Once you submit the documents your claim will be analysed as per the terms and conditions of the policy. On the basis of T&C analysis, if it fulfils all the conditions then your claim gets approved and otherwise, they will reject your claim.
  • Once the claim gets approved, the insurance company will send the final amount and letter of claim settlement along with the breakup amount mentioned on it. Further if the claim gets rejected then they will send you the letter of claim settlement with the reason mentioned on it.

Best time to take a Health Insurance Plan: The purchasing of an insurance plan is completely depending on your requirement, convenience and financial condition but it is also important to look for the right time. To purchase any health insurance policy at the right time is a young age when you are capable of earning more. At a young age everyone is flexible enough to compensate for their needs and keep aside a small amount of money to invest for health insurance. Health is precious as well as uncertain, no one can predict what will happen tomorrow, even the fittest person can have cancer or attacks. It is better to invest some money and buy an insurance plan at a young age instead of regretting the financial loss in your sixties. At old age the body is much likely to get diseases and at that time insurance companies will take high premiums to provide you coverage. Moreover, if you have any pre-existing diseases at the time of purchasing any insurance at the age of sixth then no insurance company will cover that in the policy.

If you want to make a claim with either method you have to fulfil some conditions. Only by fulfilling these conditions, you will be eligible to take claims:

  • Minimum hospitalization of 24 hours is mandatory to make a claim of health insurance.
  • You have to inform the insurance provider as soon as possible or immediately about a medical emergency. All insurance companies have their own time frames which they have to follow. If you are unable to inform the insurance provider then it will not be covered under the insurance.
  • If you are about to claim for reimbursement don’t forget to maintain a proper file attaching all the prescriptions, bills and expenses date wise.
  • Keep a clear understanding of the coverage criteria and exclusion.

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