How To File Health Insurance Claim [2022]

How do you file a Health Insurance Claim?

Health insurance plans provide the additional benefit of cost-free treatment and reimbursement for expenses by the insurance company. You can make a claim for the expenses incurred in accordance with the maximum sum insured of insurance coverage for health. The following are the two kinds of claim procedures:

1. Health Reimbursement Claim

For treatments that are offered at the hospitals outside of the network, the policyholder may make a claim for reimbursement of the cost of treatment. When the treatment is complete the insured has to pay the bill, get all of the documentation, and then submit a claim with the insurance company or TPA to receive reimbursement.

2. Cashless Claims

If the treatment was received at a hospital that is a network or a cashless hospital, the patient will be able to use cashless treatment. After the treatment has been completed, the insurance company pays the cost in full with the institution.

In the case of reimbursement as well as cashless claims, the procedures for planned and emergency hospitalization can differ according to the following guidelines:

In the event of Planned Hospitalization

    • If you plan to go to the hospital it is necessary to notify the insurance company at least 48-hours prior to the procedure.
    • Once you’ve received acceptance from the TPA Once you have the TPA’s approval, you are able to apply for reimbursement as well as cashless claims upon submission of the claim form.
    • Also, make sure to submit other documents, such as medical bills discharge summaries, reports, and so on.
    • When the approval is given when the approval is granted, the amount for the claim will be paid by the insurance company in the case of reimbursement claims.
    • In the event of claims that are not cash-based the hospital bill will be directly paid by the insurer.

In the event of Emergency Hospitalization

  • In the event of an emergency hospitalization, you must inform the insurance company within 24 hours of being hospitalized.
  • Bring your health card to the hospital
  • Complete the pre-authorization form in order to receive TPA approval for hospitalization in an emergency for cashless claims.
  • If the insurer is approved, it will settle the claim directly with the hospital in the network.
  • If you don’t receive TPA approval, you will be required to file to be reimbursed later.
  • Send all documents required such as charges for hospitalization, discharges, etc.,
  • The amount claimed shall be paid to you.

Documents required to be submitted for the Health Insurance Claim Reimbursement

If there is an admission to a hospital, the owner of the policy has to present certain documents, in the following order:

  • Card for discharge issued by the network hospital or hospital
  • In-patient hospitalization invoices that have been signed by the insured to prove authenticity
  • Medical prescriptions from doctors and bills from stores
  • Claim-form that has the signature of the insured on it
  • Report of an investigation that is valid
  • Disposables and consumables as prescribed by the doctor with full information
  • Doctors’ consultations and bills
  • Copies of the insurance policies from prior years, and the current year’s policy/copy of ID Card issued by TPA
  • Other documents (s) requested by the TPA

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