What is Claim Processing in Health Insurance & Mandatory Documents

Coronavirus is a class of viruses, and it gets its name from the ciliary-like protein projections A major confusion that many people have regarding health insurance policies is about the documents that are required to be presented at the time of making a health insurance claim. People often also get confused as to what is the process in case of cashless claim and reimbursement claim.

Documents Required For A Health Insurance Claim

You need the following documents to raise a health insurance claim:

• Filled Claim Form: The very first document should be submitted is the claim form that should be filled by the policyholder.
• Medical Certificate: A medical certificate issued by your doctor and authorised by the hospital.
• Diagnosis Report: A diagnosis report should be attached which should give the information about your health issue.  
• ID Proof: Your ID Proof is necessary to attach for claim.
• Discharge Card: The patients need to submit the discharge card to the insurance company along with the claim.
• Prescription And Medical Bills: The doctor’s prescription should be attached to the claim along with the bills of the prescription drugs and invoice of hospital and nursing charges.
• FIR (In Case Of Accident): If there is an accident then the first information report or the medico legal certificate needs to be attached to claim.

How To Make A Health Insurance Claim?

A health insurance claim can be settled in a cashless or reimbursement manner.

1. Cashless: The Cashless claims are those for which the medical treatment is sought at a network hospital of the insurance company. A cashless claim can happen in two ways - planned treatment and unplanned treatment.    

Planned Treatment: In case of a planned treatment, follow the below given steps:

Step 1: Inform the insurance company at least 4 days prior to taking the treatment.
Step 2: Submit a cashless claim request to the insurance company.
Step 3: The policyholder and the hospital would get an eligibility letter.
Step 4: Present the confirmation letter with the cashless card to the hospital at the time of hospitalisation.
Step 5: Get the required treatment done. The treatment cost will be borne by the insurance company.

Unplanned Treatment: Unplanned treatment is a treatment when there is an emergency or some issue got diagnosed which needs immediate treatment. In case of an unplanned treatment, follow the below given steps:

Step 1: In case of an emergency, visit the nearest network hospital and show the cashless health card at the hospital.
Step 2: Fill the claim form at the network hospital. 
Step 3: The insurance company will send an authorisation letter to the hospital after checking eligibility and coverage if the policy.
Step 4: You just have to get yourself treated, the charges would be again borne by the insurance company. 
Step 5: In case of rejection, the company will send a letter to the policyholder giving reasons for rejection.
   
2. Reimbursement Claims: The scenario of reimbursement arises when treatment is taken at a non-network hospital. The reimbursement claim pans out according to the below given steps:

Step 1: Take treatment at a non-network hospital, pay the bill upfront from your own pocket. 
Step 2: Submit all the bills and necessary documents mentioned above and raise a claim.
Step 3: If the company deems the claim to be eligible then the amount spent would be reimbursed. 
Step 4: If the claim is not reimbursed, the company will write an explanatory letter stating the grounds of rejection. 

Conclusion

It is not a very big issue, many policyholders do not have knowledge of this procedure and insurance agents are there to help you. But it is best to have knowledge of the documents that are required to file a claim of the health insurance policy.      

Disclaimer: This article is issued in the general public interest and meant for general information purposes only. Readers are advised not to rely on the contents of the article as conclusive in nature and should research further or consult an expert in this regard.