Claim Process

How Do I Claim For my Group Health Insurance

By May 7, 2019 No Comments

Now that the employees are insured and have a medical insurance cover, the question arises, how does one claim and what is the whole process? We will help to answer all those questions so that the claim is processed effortlessly.

How to claim?

You can make a health insurance claim in two ways –

  1. Cashless Claims
  2. Reimbursement Claims

Cashless Claim – This is a facility extended by the insurance company and a part of your policy terms where the policy holder can get admitted and undergo necessary treatment without paying the hospital directly for the medical expenses. The eligible medical expenditure which is incurred is settled by the insurance company directly with the hospital. You can avail cashless hospitalization only in the hospitals that are part of your TPA ( Third Party Administrator ) or Insurers network.

 

PROCESS OF A CASHLESS CLAIM

Please find below the procedure of cashless claim process

  • To avail the cashless facility, you can walk-in to any of the nearest network hospital.
  • Carry your mediclaim cards along with any Government of India photo Identity proof.  
  • Please inform at the hospital reception ( or TPA / Insurer Helpdesk) that you are covered under Group Medical Insurance policy.
  • Ask for pre-authorization form and get it filled by your treating doctor along with medical reports in support of diagnosed. Many Hospitals get this process done by themselves but you can check for particulars at the hospital you are going to.
  • Mail the scanned copy of pre-authorization and medical reports to your respective TPA. This too is often handled by the hospital itself.
  • Insurer / TPA will then evaluate the details mentioned in the form and process your claim within 4 hours – 6 hours ( this is typically a conservative estimate of time and can often happen much sooner) or intimate you further. This intimation could potentially be a request for more information or a denial of cashless. No denial can happen unless the treatment is not covered specifically under the policy terms. We will be happy to help in case that was to happen to re-validate the opinion of the insurance company and to challenge it on your behalf
  • The cashless may be rejected if Insurer / TPA is of the view that the ailment/ hospitalization are not covered under this policy.
  • At the time of discharge if the claim amount is more that your sanctioned amount, the Insurer / TPA will mention it in the approval note and you may have to bear that yourself. The common head’s under which this partial approval may happen are –
    1. Your sum insured is exhausted.
    2. Non Medical Items that are not covered under the scope of any health insurance cover in India.
    3. There is a provision of cost bearing on your part, as a policy feature under your policy, often called co-payment.
    4. There is a capping for the particular treatment in your policy.
  • Few hospitals may ask for initial deposit at the time of admission. This is a subjective demand and varies from hospital to hospital. Any amount that you have paid, after adjustment for the details mentioned in the previous point above, will be refunded to you.
  • At the time of discharge – The patient and family are obviously eager to get home at this point in time. We would like you to calibrate your expectations on this. While the treating doctor may advise discharge the previous day or the same day, the sequence of processes that a hospital needs to follow are many. THis process itself at the hospitals end, often can take a few hours. Finally once the hospital generates the final bill and discharge summary, they will send it to the Insurance company / TPA. This is then put into a detailed scrutiny by them and a doctor will also evaluate all the documents. Once they have validated all details and mapped it against the policy terms, they will approve the claim and also the amount that they will pay. THis will then result in the Final Authorization being sent to the hospital.
  • On receipt of the Final Approval / Authorization, the hospital will let you know via the billing department if you need to pay any balance, assuming the approval is done. You can pay that balance or challenge it ( in which case seek us out and we will understand your point of view and represent it to the Insurer / TPA)

Reimbursement Claim – This facility is opted by the claimant when he goes to a hospital as per his choice given that it is a non network hospital. Cashless process cannot be availed here. The claimant has to pay for all the medical expenses and other costs  incurred during the hospitalisation. After discharge, the claimant has to provide all the original documents to the insurance provider. The provider will scrutinise all the document as per the policy terms and conditions and make the payment to the employees. In case the treatment is not covered, the claim is rejected and a reason is provided.

DOCUMENTS REQUIRED FOR REIMBURSEMENT –

Following original documents are mandatory to process a claim under reimbursement.

Please note the hospital should a minimum of 15 beds. (Read Here for more details on Bed Requirement for it to be qualified to be eligible for claim payment under health insurance)

  1. 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 )
  2. Claim Form duly signed. This is absolutely mandatory
  3. 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)
  4. 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
  5. 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.
  6. 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 letter head
  7. Others medical document that may be provided
  8. 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
  9. Copy of photo identity card of patient and employee
  10. Pharmacy bills.
  11. MLC Report & Police FIR, Alcoholic declaration in case of accidental cases particularly Road Traffic Accident (RTA)
  12. Also in RTA Cases, detailed circumstances of the trauma with date, place and time. This is mandatory for reimbursement claim in case of an accident case.
  13. 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
  14. Original cancelled cheque, with printed name, for the transfer of payment to your bank account. If you providing cancel cheque without printed name please submit the copy of passbook with bank attestation. Bank E-statement (In case your name as an employee is NOT printed on the cancelled Cheque)

Points to keep in mind while filling the claim form for reimbursement process  –

Kindly mention your Employee ID, Company Name and Contact details on top of the claim form (You can write this at the right top portion).

Please note that the following fields are mandatory in a claim form –

  1. Policy Number (in case of Corporate policies, even if you don’t have the policy number, that’s fine, you can omit it.
  2. Cashless Identity Card number ( would be mentioned on your hard copy or E Card in case you have that).
  3. Name of the Insured ( Primary Member) with addresses and contact details.
  4. Name of the Corporate & Employee code.
  5. Name of the Patient, date of birth and relationship with the employee.
  6. Tick on the type of claim, write, and date of admission and discharge, name, address and contact details of the hospital.
  7. Provide the details of illness / injury / disease.
  8. Provide the details of amount that is being claimed with breakup of bill numbers.
  9. All documents in original.
  10. Signature of the claimant along with place and date (this is mandatory).

FAQs –

  1. Is there any clause for intimation to process my claim?

You should intimate the TPA within 24 hours of hospitalization in case of unplanned / emergency cases and before 48 hours of hospitalization in case of planned treatments. This will be applicable for both cashless as well as reimbursement cases.

      2. How should I plan my treatment for cashless hospitalisation?

You can plan for cashless hospitalisation before 4 days before the date of treatment. The insured must notify the insurance provider via mail for planned hospitalisation. The insured is required to provide his/her government approved identity card at the TPA desk in the hospital. A pre authorisation form is required to be filled by the insured. After this step is done, the TPA will get the approval done. On the day of admission in the hospital, the insured is required to show his/her identity card with the approval letter. The payment will be settled by the insured provider and the hospital directly.

      3. Will I be able to claim if I submit my claim documents  after the policy expiry date?

Yes, the claimant can claim in cases when the admission date for hospitalisation is prior to the policy expiry date. After the claim documents will be received, the claim will be processed as per the policy terms and conditions.

  • Note that the employee has to make sure that the intimation is provided by the claimant to the insurance provider within 24 hours of hospitalisation.
  • The claim documents will have to be submitted within 30 days from the date of discharge to avoid the delay of submission of claim documents.  

  4. Can I lodge more than one claim for the same diseases?

Yes, your mediclaim policy covers 30 days pre-hospitalization expense reimbursement and 60 days post-hospitalization expenses. You may lodge your pre-hospitalization claim along with hospitalization claim. The post-hospitalization claim may be lodged after 60 days of the hospitalization. However, please quote your Claim Number for easy referral and sorting.

   5. In case I require my original medical papers back for future reference, what should I do?

Please carry a complete set of photocopied documents when you lodge your claim. The relevant original documents will be returned to you after verification. The TPA will however stamp the original documents. Please note that normally, the original doctor prescription, medicine bills and discharge summary along with the hospital bills will be retained by TPA. Only X-ray films, ECG, other medical records will be returned to you as a special case after verification / approval of TPA’s medical team.

6. During the course of my treatment, can I change the hospitals?

Yes, it is possible to shift to another hospital for reasons of requirement of better medical procedure. However, this will be evaluated on the merits of the case and as per policy terms and conditions.

7. Can I get outpatient treatment using my Ecard?

No. The TPA Card is issued against the mediclaim policy which only covers hospitalization expenses. It cannot be used for outpatient treatments as OPD benefits are subject to the policy terms and conditions of the policy copy.

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