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Insurance Claims

Why is claims support an important aspect to look at when finding the right insurance partner?

There are many aspects that you as an HR head or owner of a small business/start-up needs to consider while buying a product such as a group health insurance for its employees. After all, it is a top priority to focus on the welfare of your employees, which ultimately leads to the growth of your company, even in a competitive environment. 

You need to find the most suitable insurance partner that will take care of your specific requirements. It is a good step to choose a broker that can offer you many types of options in health insurance plans for businesses in India.

Before you decide to purchase the insurance, it is essential to enquire about the support provided by the insurer on claims management. It is an extremely important aspect that you should not overlook. Let us understand why claims management is the most critical factor you need to evaluate before finalising the insurer. 

Health Insurance Claims Process:

Health Insurance is a medical insurance given by an insurance company, wherein the medical expenses incurred for a valid hospitalization is either paid directly by the insurer to the hospital (provider) or it is reimbursed to the member who has incurred the expenses for treatment. The expenses for hospital bed, nursing, surgeon’s fees, consultant doctor’s fees, cost of blood, operation theatre charges are all covered. 

Broadly, there are two types of claims settlement models in health insurance: 

  1. Cashless claim process:  In a cashless claim model, the expenses incurred by the insured member is paid directly to the hospital by the insurer. There is very little out of pocket expenses incurred by the insured person as the insurance company takes all the responsibility to pay for the cost of treatment to the hospital. 
  2. Reimbursement claim process: Here the insured member pays the treatment costs to the hospital and then takes the reimbursement from the insurer. There is significant out-of-pocket expenses from the insured member as he/she needs to first file the claim with the insurer and submit all relevant documents for processing the claim. 

The claims process is the defining moment in any insurance policy. Often this is referred to as “Moment of Truth ‘‘ in the contract between an insurer and customer. An effective claims management process becomes a unique value proposition for insurers and is one of the most important and effective ways to acquire, retain and manage customer relationships.

Faster Claim Management Process

Settling insurance claims is just one aspect of the claims management process. The time it takes to process a claim involves several stages beginning with a person filing a claim. The stages that follow determine if a claim has merit as well as how much the insurance company will pay.

Insurance customers expect a company to settle claims quickly and to their satisfaction. Because high customer satisfaction levels can give a company a competitive edge, reducing the time it takes to settle insurance claims is one way to decrease the number of customer complaints and improve service. 

Main tasks of the claims support team

  1. Documents needed to apply for claims

As a dedicated partner of the client an insurance partner should also be aware of the list of documents you need to apply for the claims. The policy papers will mention the documents. Still, enquire the details from the insurer and/or support team. It is always a better idea to go through the official document of the support team or the insurer that mentions the series of tasks and responsibilities of the claims team. 

The right partner patiently goes through the clauses and related sub-clauses that explain the functions of the claim support executives. 

  1. Go through the website of the insurer

You should check out the website of the insurer to know more about its claims support platform. Take your time to explore the various aspects of the claims support services. You can take note of points that can provide you insights in this regard. 

  1. Seek suggestions from experts

It is a wise step to seek advice from experienced professionals who know about buying health insurance policies from top service providers who also have a claims support team. Discuss the things that play a major role in the process. You can prioritize the bits of information.

  1. Timelines: 

Procedure for claims submission, time lines and possible course of action, if time lines for claim submission are not adhered to along with all the claims documents required for claim processing, then the insurer can take stance in denying the claim. Hence dedicated claim support is very critical in finding the right partner for your insurance. One of the key responsibilities of the partner is to ensure timelines for reporting, submission and settlement processes are streamlined and followed with vigour.

Expert Advice:  

Not all health insurance claims are paid by the insurer. There are a lot of claims that ca be rejected as power the terms and conditions of the policy, Once a claim is denied or repudiated, the communication about the denial or the repudiation shall be made by the insurer by specifically stating the reasons for the denial or repudiation, while necessarily referring to the corresponding policy conditions. The insurer generally also furnishes the grievance redressal procedures for the insured. The right insurance partner should provide the expert advice if a claim is rejected by the insurer. Understanding of the technical language, terms and conditions of the policies will ensure the partner is able to represent their clients ( insured) to the insurer for taking up rejected cases. 

PlanCover is a preferred “Health Insurance” partner for progressive businesses helping their employees reduce stress and giving them  “Peace Of Mind”. They have helped more than 1,250 customers buy group insurances in the last 12 months. One of the key value propositions they could deliver is on claims management. With a deeper relationship with the insurers and a dedicated team for every single claim, PlanCover has ensured 100% of claims are settled within 12-15 days which is up to 60% faster than the market. 

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