How to make a hassle-free health insurance claim!

We often read or hear about health claims being rejected by insurers on flimsy grounds. Sometimes, however, the insured is also to be blamed simply because he/she is found to have made false declarations while taking the policy or failed to go through the fine print before buying one.

True, health covers are bought with a view to taking cover against any financial constraint that may arise because of a medical emergency, and insurance companies are bound to honour legitimate claims within policy limits. At the same time, however, it must be understood that insurance companies are not charitable organisations. Therefore, they can’t be expected to honour a claim if the claim is not made in accordance with agreed terms or if a particular disease is listed under the policy exclusions.

“The repudiation of a claim may be due to many reasons such as loss falling beyond the scope of policy coverage, exclusions under policy, or breach of conditions or warranties, among others,” says Shreeraj Deshpande, head – health insurance, Bajaj Allianz General Insurance.

Generally, however, “the primary reason for an insurer rejecting a claim is that a particular disease is listed under the policy exclusions and consequently cannot be covered,” says Ajay Bimbhet, managing director, Royal Sundaram Alliance Insurance Company Ltd.

Therefore, only getting a health cover is not enough. It is equally important to read and understand the terms and conditions of a policy well and be clear about the policy you plan to take in order to avoid any hassle or heartburn in the future. It would also help if one knows how to make a claim and what to do in case something goes wrong.

DIFFERENT MODES OF SETTLEMENT

While buying a health policy, the customer is required to opt for either cashless or reimbursement mode of settlement. In both the cases, however, it is important to understand the claim procedure laid down by the insurers. Simply because at the time of emergency, the understanding of the right procedure can help reduce unwarranted panic.

CASHLESS CLAIMS

Insurers have tie-ups with a network of hospitals across the country. If the customer opts for cashless claims, he/she has the facility of cashless treatment at the networked hospitals. This list of the network is generally available in the policy kit and also on the website of the insurers.

“In case of emergency hospitalisation and admission, the TPA (third party administrator) needs to be intimated through a toll-free number within 24 hours. In case of a planned admission, however, the TPA is to be informed three days in advance. Also, the insured must remember to quote his/her health card membership number and/or policy number,” says Bimbhet.

While getting admission, the cashless request form available with the hospital insurance help desk is to be filled and certified by the doctor. Having done that the form with supporting medical records is to be faxed by the hospital to the TPA’s fax number.

On scrutinizing the documents, the TPA conveys the decision to the hospital, the sanction of the cashless request or calls for additional documents if required.

On approval of the cashless facility by the TPA, the hospital bills are settled directly by the insurer (subject to policy limits). However, inadmissible amounts such as telephone, food and attendant charges are to be borne by the customer.

If the customer chooses to go to a hospital which is not part of the network, he/she can still get a reimbursement directly from the insurer.

REIMBURSEMENT OF CLAIMS

This facility is available at network hospitals as well as non-network hospitals. Under this facility, the insured can avail of treatment and settle all the bills with the hospital and file a claim for reimbursement. The insurer, however, has to be intimated immediately on admission not later than seven days from the date of discharge. The policy certificate number should be quoted and the claim can also be intimated online through the website of the company.

Generally the following claim documents (originals only) are to be submitted to the insurer within 30 days from the date of discharge:

1. Duly-filled claim form along with the doctor’s certificate (forming part of claim form)

2. Discharge summary

3. Bills and receipts (including advance and final receipts)

4. Prescriptions for medicines and doctor’s advice for lab tests

5. Diagnostic Test Reports, X Ray, scan and ECG and other films

Claims are processed on receipt of all required documents and additional documents. Information, if any, required is called for after the scrutiny of the claim. “The cheque is despatched to the customer if the claim is admissible. If not, a repudiation letter explaining the reasons for denial is sent,” says Bimbhet.

PRECAUTIONS/DOS & DON’TS WHILE BUYING A COVER

You need to exercise precaution not only while making a claim, but also while planning to buy a health cover, because here you start with choosing the right product for yourself, and opting for any unsuitable one may land you in trouble later on.

First, you need to understand whether the health insurance coverage fulfils your requirement or not. Then decide on which members of your family should be part of the health insurance policy. Ideally everyone should be covered including children.

The third step would be to settle on the total amount of health coverage needed – either on an individual basis or on a family floater basis. Besides, you also need to scrutinise the list of exclusions of the policy – both permanent and period-based.

Also check the network coverage of the Third Party Administrator (TPA) engaged by the insurance company.

PRECAUTIONS/DOS & DON’TS WHILE MAKING A CLAIM

You need to take precautions while filing a claim too. For instance, in case of a cashless claim, always carry the health card which gives you the unique membership number that is used by the TPA to identify you and provide the cashless benefit.

In the case of reimbursement of claims, however, always insist on getting the original discharge summary and reports from the hospital.

Also keep copies of all lab reports for future medical follow-ups, and retain copies of all claim documents before submission to the insurance company (This will help in case of an unfortunate event of the documents getting lost in transit).

Besides, insist on getting a properly-numbered, stamped, signed and sealed receipts from the hospital/ physician / surgeon for any payments made. Preserve the prescriptions given by the doctors for medicines and lab tests as these are to be submitted along with other claim documents.

For all traffic accidents, however, ensure that a complaint is lodged with the police and get a copy of the FIR.

WHAT IF AN INSURER REFUSES TO HONOUR A CLAIM?

Despite choosing a heath cover carefully and filing the claim as per the agreed terms, sometimes claiming insurance compensation becomes a hard nut to crack, particularly in cases when insurance companies are able to find some loopholes to repudiate a claim. In such cases, you need to approach higher authorities to seek compensation.

“If an insurer repudiates a claim, insist on a repudiation letter which explains the basis on which the claim is repudiated. If the customer is not happy with the contents, he may represent the claim again as per the escalation matrix in the grievance redressal machinery. If the customer is still not satisfied, he/she may approach the insurance Ombudsman, whose decision is binding on the insurer,” says Deshpande.

Thus, if a customer is not satisfied with the response of the insurer, he/she can always approach the Ombudsman who is specially appointed by the regulator to redress the grievances of the customer. The complaint by an aggrieved person has to be made in writing, and addressed to the insurance Ombudsman of the jurisdiction under which the office of the insurer falls.

“The governing body has appointed 12 Ombudsmen across the country allotting them different geographical areas as their areas of jurisdiction. The Ombudsman may hold sitting at various places within their area of jurisdiction in order to expedite disposal of complaints. The Ombudsman shall pass an award within a period of three months from the receipt of the complaint. The awards are binding upon the insurance companies,” says Bimbhet, adding, “the policy holder also has the option of approaching consumer forums and courts of law for redressal of his/her grievances.”

However, if you are still unable to get justice, then just blame your luck! And what else can you do?

Source:www.economictimes.com