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Health Insurance Claims: The Basics


Gone are the days when health insurance was considered just another fancy term for an added expense you don’t really need. Today, there is a lot of awareness on how medical insurance can be your safety net in case of a medical emergency, be it an illness or an accident. There is also, the obvious benefit of tax savings!

Experts suggest that health insurance has become an essential element of any family’s investment plans, to combat rising health risks as well as skyrocketing charges for healthcare services.

Generally, an insurance claim can be done in two ways – cashless and reimbursement. Here are some pointers on how to go about making your claim:

Cashless Claims

A cashless claim can be made when you are hospitalised at a ‘Network Hospital’, or a hospital that is recognised by your health insurance provider. This is, undoubtedly, the best way to go about your claim because it saves you the burden of dipping into your savings and shelling out your hard-earned money for the treatment.

In terms of a cashless claim, most of the paperwork is taken care of by the hospital or the third-party administrator (TPA) your insurance company is linked with. A good policy provider would ensure that this process is fast and smooth, using a claims management application to do so.

If you are looking to make a cashless claim, you will need to:

  • Submit your policy/membership number to the hospital for preauthorisation from the TPA
  • Submit relevant documents relating to your personal information and planned treatment, which will be available at the hospital’s insurance helpdesk
  • At the time of your discharge from the hospital, verify and sign all the bills incurred
  • Leave the original bills at the hospital and keep photocopies with you for your reference


Reimbursement Claim

Reimbursement claims can be made when there has been a medical emergency when you have been unable to seek treatment from a network hospital. As the name suggests, this type of a claim is one wherein you are expected to pay all your bills at the hospital and later have them forwarded to the TPA for reimbursement. When you choose this method to make your reimbursement claim, it is important to make sure that all relevant documents required by your insurance provider have been compiled before the request is filed. This can save you the hassle of claim rejection and multiple resubmissions.

To process your reimbursement claim, you will need to:

  • Pay for all expenses incurred during and after the treatment at the non-network hospital
  • Collect all bills, documents and medical reports at the time of your discharge
  • Lodge a claim request with the TPA by submitting the relevant documents


Terms & Conditions

There are a number of variations in the health insurance plans offered by different policy providers. It is therefore key to understand, first and most important, the meaning behind that little asterisk (*) – the ‘terms and conditions’ of your policy.

Although it may seem like a long and arduous task, you need to take the time to read and understand what is and isn’t covered in the healthcare policy you are signing up for. Can you claim the expenses for outpatient treatment or is it restricted to hospitalisation? What is the total amount you can claim in a year? Are additional expenses like room rent and charges incurred for the care-giver covered? Are there limitations in the amount of cover received for specific treatments or certain health conditions? These are the questions for which you need to be finding the answers to as you read the policy document and make your decision to invest in the policy.

Knowing the answers to these questions ahead of time and understanding the specifics of your policy plan will help you be prepared when a need arises, and help you go about your claims procedure in a hassle-free manner.

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