Insurance is a very technical concept by its nature. Although people buy it understanding its needs and benefits. However, at the time of claim, they almost feel clueless. The claims journey is the most critical part in any insurance purchase and hence this is also often referred as “Moment Of Truth” in any insurance policy.
Every health insurance claim indeed has a protocol, but understanding the simple process can help people claim the benefits without any dilemmas.
Claim settlement is one of the key factors in a health insurance policy. A health insurance policy is about getting a financial backup in case of medical emergencies.
Group Mediclaim Policy or Group Health Insurance policy is a health plan offered by an employer, which provides coverage to all of its employees under the same insurance policy. Employees who are above the age of 18 and below 70 and are employed with a company are eligible for a group mediclaim policy. It is a common health policy that is extended by every organization in India today.
Key features of group health insurance/ Mediclaim cover include:
- Customized and tailor-made policy
- Provides cashless facility to the insured
- Covers pre and post hospitalization costs
- No physical check up required
- Coverage for pre-existing illness
- Coverage for dependents
- Pocket friendly premiums
- Covers critical illness etc.
In any health insurance policy, the claims can be settled in two ways:
- Cashless claims
- Reimbursement claims
Cashless Claim Facility
The most important feature in a group health policy is the payment of claims is done directly with the hospital. Under health insurance terminology we call it cashless claims. To avail of the cashless facility, the insured has to get the treatment done in the network hospitals empanelled with the insurance company. The hospital needs to be notified of the details of the insured person during the time of admission. Further, the hospital informs and coordinates with the insurance company and the bill is directly paid to the insurer.
Network hospitals are the hospitals that have a tie-up with the insurance companies.
Medical Identity Card: Medical Identity card falls under cashless services. Some insurance providers issue a medical card to each of their insureds, to shorten the tedious paperwork. They intend to provide a hassle-free, and smooth experience of cashless services to the insured person. A single medical identity card covers the insured person and the family members in case of need.
How to claim cashless health insurance in a hospital?
To avail the cashless health insurance in a hospital, the insured needs to follow the below process:
- The insured needs to avail the medical treatment in one of the empanelled hospitals.
- The insured needs to provide the details of the health insurance policy and the medical identity card to the hospital.
- If the medical treatment availed by the insured is covered under the health insurance plan, then the insured can get the health insurance claim.
- On receiving the medical treatment successfully, the bills and details of the treatment are sent to the insurance provider.
- The insurer evaluates and verifies the details and settles the payment.
However, the claim process varies from hospital to hospital and according to the type of payment which are:
- Planned Treatment
- Unplanned Treatment
Under planned treatment, the insured person needs to inform the insurance provider about the hospitalization or the treatment required ahead of time. The insurance company should receive the information at least 4 days earlier in order to receive the cashless claim service.
A cashless claim form is to be filled and submitted to the insurer, which is mostly via email, fax or post at the valid address. Once these steps are completed, the insurance provider notifies the insured and the hospital about the medical treatment, about the cover and its eligibility. The insurer allows and places a payment guarantee with the hospital to ensure there is no interruption in the treatment process. On the day of discharge the insured displays the medical identity card to the hospital and the confirmation letter. The medical bills are then settled by the insurance provider, directly to the hospital.
Treatment provided in case of emergency is referred to as unplanned treatment.
- In case of any such emergency the policyholder needs to first contact the help desk in order to transfer the information to the nearest network hospital.
- By displaying the medical card, the policy holder can avail the cashless treatment. The hospital has to fill in the cashless claim request form and submit it to the insurance provider via email, fax or post.
- An authorization letter is issued by the insurance provider to the hospital specifying the policy coverage and eligibility.
- The medical bills are then settled directly to the hospital by the insurer on the day of discharge of the policyholder.
- In case of rejection of a claim, the insurance company informs the hospital and the policyholder with the reason for rejection.
How does cashless medical insurance work?
Cashless health insurance eliminates the hassles of paying cash at the time in the hospital at the time of need. For cashless claim health insurance, the insurance providers directly negotiate their terms with hospitals within their network, to directly settle the bill.
Following documents are required in order to make a cashless claim.
- Duly filled cashless claim request form.
- Medical treatment certificate, issued by the doctor/physician.
- Original discharge summary, available from the hospital.
- All original bills and receipts.
- Prescription and cash memos of pharmacies.
- Investigating report.
- In case of an accident, an FIR report is also required.
Advantages of Cashless Claim
- There is no financial burden on the insured to avail the medical benefits in the hospitals.
- There is minimal paperwork involved in such cases.
- Direct settlement of the expenses from the insurer will ensure the insured person is taking care of the treatment in the best of class medical facilities and hospitals without any burden to his finances.
Disadvantages of Cashless Claim
- The insured needs to avail the treatment only in the network hospitals in order to avail the benefit of cashless claims.
- In case of emergency, one might not be able to find a network hospital or might rush to the nearest hospital available.
- In such cases, cashless services are not extended by the insurance provider.
Major insurance companies have built their plans in such a manner that the insured can take advantage of the cashless claim services easily. As the insurer understands the benefit of it and they want to provide a smooth and hassle free claim settlement process to their customers. It provides a liberation to the insured to waste time on medical bills, when insurance companies can take care of it.
Reimbursement claim process
Under the reimbursement claim process, the insured can get the treatment from the choice of the hospital before applying for a claim. Reimbursement can be claimed for the medical services included in the policy purchased by the insured person. The payment of the claim is subject to the terms and conditions of the health insurance policy. Nothing beyond what is mentioned in the policy papers is provided to the insured person.
The insured person has to submit a claim form to the insurer for claiming the benefit under the reimbursement process. Please note that the following fields are mandatory in a claim form
- Policy Number (in case of Corporate policies, even if you don’t have the policy number, that’s fine, you can omit it).
- Cashless Identity Card number ( would be mentioned on your hard copy or E Card in case you have that)
- Name of the Insured ( Primary Member) with addresses and contact details
- Name of the Corporate & Employee code
- Name of the Patient, date of birth and relationship with the employee
- Tick on the type of claim, write, and date of admission and discharge, name, address and contact details of the hospital
- Provide the details of illness / injury / disease
- Provide the details of amount that is being claimed with breakup of bill numbers
- All documents in original
- Signature of the claimant along with place and date (this is mandatory)
All documents to be filed under the claim have to be in Originals
Once the claim form is filled you need to submit the claim form along with all mandatory documents. Following original documents are mandatory to process a claim under reimbursements
- Copy of Hospital Registration Certificate with Registration number and number of beds certificate (This may not be required in case of larger hospital which are well known and in larger towns / cities )
- Claim Form duly signed. This is absolutely mandatory
- Copy of the Claim Intimation, if any ( If you are filing the main hospitalisation expenses for reimbursement, then you would have done the intimation of the claim in advance, as per your policy terms. Do attach a copy of that)
- Hospital Main Bill with proper breakup of the expenses. Often there is a summary bill and then there is a bill which mentions all line item wise expenses. The insurer will need the detailed latter bill
- Hospital Bill Payment Receipt for which the policyholder / claimant made the payment to the hospital. Do note that this receipt will need to be numbered.
- Original Hospital Discharge Summary (which should clearly mention –
- Patient name
- Date of Admission
- Date of Discharge
- Age of the Patient
- Final Diagnosis
- Case Summary / History (On Examination), Course in Hospital, Line of Treatment, Advice at Discharge with signatures and stamp of treating doctor. This will be on the hospitals letterhead
- Others medical document that may be provided
- Doctor’s Prescriptions. Often in non-emergency cases, the patient is first shown to the doctor n OPD basis, In such cases all doctors prescriptions will be needed
- Copy of photo identity card of patient and employee
- Pharmacy bills.
- MLC Report & Police FIR, Alcoholic declaration in case of accidental cases particularly Road Traffic Accident (RTA)
- All Investigation Films and Reports – ECG / CT / MR / USG / HPE or any other investigation reports. Obviously there will be no films in cases of blood investigations, urine / stool investigations or biopsy
- Original cancelled cheque, with printed name, for the transfer of payment to your bank account. If you provide a cancel cheque without a printed name please submit the copy of the passbook with bank attestation. Bank E-statement (In case your name as an employee is NOT printed on the cancelled Cheque).
Insurers will take a minimum of 15 working days to process the reimbursement claim and transfer the amount directly to the insured person’s bank account.
PlanCover, a leading insurance broker in India, has been working tirelessly and helping their customers in the claims process. They have processed over 200,000 claims under the group health insurance policies for their clients in the last decade and have built very deep expertise in claims processing. With PlanCover, you can find group policies within the budget from the IRDA-approved insurance companies in India. Connect to the proficient team and find better ways to reduce the insurance premium without losing out on the plan features.