Dos and Don’ts When Filing a Health Insurance Claim

Health insurance is not merely a preference anymore; it has perfectly taken the importance of a necessity, all there to secure us financially against almost all health odds!

With anytime availability of applying for insurance online, getting a health insurance policy is now just a matter of a few good clicks. But with ease, we can’t sit back on the responsibility front. While applying for the policy, specifying the requisite details must be ensured with utmost honesty. Specifying every minute detail about our health history is highly important to make sure the claim settlement goes smoothly in future (if needed).

It is highly important that we must provide adequate information to the insurer while buying the insurance policy. If we expect to be safeguarded with a health insurance policy, then we have to make sure of complete transparency while providing the details in the policy.

Even after buying the insurance, many of us are skeptical or feel anxious about whether the medical expenses in case of emergency or hospitalization will be settled in a hassle-free way or not. Most of us even think that paying premiums timely is the major criterion for getting claims processed on time, but what we must know is that claim settlement process is dependent on a lot of factors. Here are a few Dos and Don’ts to help you understand what all should one do for quicker claim settlement:

Dos

1. If it’s cashless one, it’s important that you inform the insurance company at least 2 days before you have been asked to get admitted in the hospital. In case if it’s an emergency hospitalization, it’s important to inform the insurer within 24 hrs of hospitalization or as detailed in the policy.
2. In case of a planned hospitalization, it’s important to provide OPD consultation papers.
3. Never forget to verify the statements provided before signing any document; no changes should be made in the statement without providing substantial proof.
4. Pre-Authorization form is important, and verifying every minute detail along with the medical history is advisable before signing it.
5. The information and details provided regarding the hospitalization should be true, and once everything is checked, submit all the necessary documents.
6. All the original documents should be submitted directly to the insurance company. Also, a copy of all these documents can be kept for reference in future.
7. The correct contact details should be provided and verified before submitting.
8. While the claim process is on, prefer keeping in touch with the customer care of the insurance company/TPA Desk and ward staff at the hospital, all through the hospitalization.
9. If the hospital isn’t one of the network hospitals and you want the reimbursement, then collect all the needful documents, and access where to send across to start the claim process.
10. It’s mandatory to provide all the relevant information including a number of health insurance policies, pre-existing health conditions or diseases etc. An honest declaration can end up in a slightly higher premium amount, but will ensure a smooth settlement process, whenever needed.
11. Documents like first consultation, medical advice on getting hospitalized, all the receipts, tests performed, discharge certificate, pharmacy specifications, signed hospital bills, etc., should be provided in original.
12. It’s important to renew the policy on time to avoid expiration and enjoy continuous coverage, and premiums must be made on time to ensure better consideration.
13. Any development or alteration in the subject matter of the insurance should be updated with the insurer; this will ensure continued coverage under the policy.

Now, before we discuss on to the don’ts, let’s understand in which all ways we can claim under a Health insurance policy:

Ways to Claim under a Health Insurance Policy

There are 2 ways we claim under a Health Insurance policy, based on the policy taken and the mode preferred:

1. Cashless basis
2. Reimbursement basis

On Cashless Basis: If the claim is on a cashless basis, then it is advisable to get the treatment at one of the network hospitals of the Third Party Administrator (TPA) who you have taken the insurance policy from. In this type, you need to have proper authorization for getting the treatment, everything should be done as per the specified procedure and as laid in the prescribed form. It is advisable to go through the policy document thoroughly whenever you receive it, as this will help you to understand the procedure well, & you wouldn’t have to rush through at the time of hospitalization while making the claim.

Reimbursement based claim: As for the cashless claim, when you receive the policy document, going through all the necessary clauses related to this reimbursement claim process is important. This will help you to understand the procedure and know about the documents required while making this type of claim. When the time arrives for the claim, you must inform the insurer as per the procedures required. After paying for the hospitalization, you will have to keep all the needed documents ready. Documents such as claim form, discharge summary, prescriptions, and bills should be kept in original to submit for a claim.

…And Now the Don’ts

1. Dishonesty in specifying details can lead to cancellation of policy or a chanceful potential of refusal in settling claims. Falsification of claims will not only lead to forfeiting the benefits, but no insurance company would like to continue business with someone proved as dishonest.2. Unreasonable in making claims, making repeated and small claims will eventually make things questionable, and might even results in hikes the premiums along with claims getting dismissed.3. Any delays in informing, intentional or unintentional, can go against you in the claim settlement process. There is a specified stimulated time in which the loss must be reported to the agent or in which the admitting of the patient should be intimated. The company follows a strict and prescribed process for which on time submission of documents and a particular time required in checking & verifying the documents needs to be fully considered.
2. If in any case, details about the loss or hospitalization are not fully available, then the insurance company should be notified to this effect, and it’s important to seek permission for time extension to submit all the necessary documents.
3. Do not miss out on mentioning any necessary details about your heath history, any disease or medical condition or personal specifications, no matter how small, should be mentioned, in case of any forgery found in specifying any necessary details the policy might stand void-ab-initio.
4. Guesstimating your weight, height, identification mark, or any other specifications in the application form can go against you and can even be a big hurdle in the claim settlement process.
5. Not going through the proposal form carefully and signing it, leaving blank spaces for agent/company representative to fill it is a big NO NO. Carefully go through the form and fill it personally along with the signature after going through the filled form again.
6. It is important to countersign any corrections made or overwriting done in the insurance proposal form.

Following these simple instructions will majorly aid in ensuring a smooth insurance claim settlement. Know about such pitfalls in advance and avoid making any untrue specifications as these can result in uncalled call-offs. Make time, put in needful efforts and precautions at the time of filing the insurance claim and more importantly, at the time of purchasing a policy. This will enable you to make the most of your insurance policy, then be it an health insurance policy,medical insurance policy, health insurance plans, family health insurance, or critical illness insurance.