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In view of the increasing medical care expenses every year, a huge gap is created between treatment cost and affordability. For bridging this gap, a health insurance cover is necessary. When a person gets hospitalized, he/she can avail health insurance claim in two ways, which are cashless claim or reimbursement claim settlement process. But many aren't aware of the difference between the two processes which is the main cause of last-minute hassles.
The cashless claim settlement process is opted when the person insured's hospitalisation occurs in any of the network hospitals as mentioned by the insurance provider. Under this option, the person insured doesn't need to shell out any money for treatment except for certain non-medical expenses. The cashless claim settlement process is a direct mode of paying the hospital bills by the insurer. In this process, the insurance company directly settles the hospital bill up to the sum insured, and the terms and conditions mentioned in the policy document. The health insurance claim can be availed for both unplanned and planned treatment at the network hospital.
Cashless claim can be availed for both planned and emergency hospitalisation, provided the treatment is taken from a network hospital only. The steps are as explained below:
For the health insurance claim, the policyholder needs to follow the below steps:
Step 1: In case of planned hospitalisation of the policyholder, the person insured needs to take pre-authorization from the policy provider. It includes informing the policy provider about the treatment. The insurer will verify the application and the expenditure in detail. The approval takes around 3 to 8 days, but it varies from insurer to insurer.
Step 2: After informing the policy provider, the person insured will need to fill up a form and share medical documents as required by the policy provider company. After sharing the necessary documents, the insurer will verify the documents and evaluate the treatment according to policy terms. After the evaluation, the insurer will intimidate if the health insurance claim can be availed or not.
Documents Required: The policyholder will need to provide the following documents at any of the network hospitals along with necessary documents as mentioned by the policy provider. They are:
Step 3: After the treatment is completed, the person insured needs to leave all the original documents like hospital bills and other such bills at the hospital. The hospital will share the bill to the insurance provider, and the insurer will process the payment.
In case of emergency hospitalisation such as an accident, the policyholder must follow the below steps for claiming the policy:
Step 1: One must inform the concerned insurance provider. On reaching the hospital, the person insured should request for cashless hospitalization.
Step 2: After the request, the hospital TPA desk will fill a pre-authorised request form and share details related to the surgery or medical treatment required by the policyholder. The same form dully signed by the insured and the treating doctor along with the required documents will be submitted to the insurance company. Upon approval, the insurer will issue a letter to the hospital, stating that the claim has been accepted.
After the treatment is completed, the insurer will settle the claim.
In case a cashless claim is rejected, the insured still will have another option to claim his/her policy. That’s called reimbursement claim. When a claim is filled for availing treatment at a non-network hospital, it comes under reimbursement category.
The reimbursement process can also be used for the settlement of a health insurance claim. This option is usually chosen when the person insured chooses to get admitted at a non-network hospital. In a non-network hospital, cashless settlement is not available. In such cases, the person insured will have to pay for all the expenses incurred during the treatment and file the claim later for reimbursement of the expenses. The reimbursement process is as follows:
One should follow the below steps to claim health insurance policy under reimbursement process:
Step 1: The person insured needs to inform the hospital 4 - 10 days before hospitalisation. He/she needs to fill up a form stating the reason for hospitalisation at a non-network hospital and the kind of treatment to be undergone.
Step 2: The person insured is required to submit all essential documents like original medical bills during claim filing. The documents are bank details, insurance ID card, hospital discharge bills, diagnosis report, original hospital bill, pharmacy bills, along with other receipts and prescriptions.
Step 3: The policy provider will evaluate the documents and verify the bills paid with the hospital.
Step 4: After the verification process, the policy provider might ask for additional documents before proceeding with the claim reimbursement process.
Step 5: After the evaluation process, the policy provider will reimburse the necessary documents as per policy terms. In the case of claim rejection, the insurance provider will notify the reason.
For emergency hospitalisation, the person insured must notify the insurer within 48 hours of hospitalisation.
Step 1: The hospital will file a claim form for the treatment required by the person insured.
Step 2: After the treatment is completed, the policyholder will need to send original documents like hospital bills, diagnosis expenses, medical test bills, and original hospitalisation bills along with an FIR copy for accidental hospitalisation.
Step 3: After verification of the documents, the policy provider will initiate the reimbursement process and refund the money within 7-10 days, but it varies from insurer to insurer.
Both the claim processes come with their share of advantages and disadvantages. Let’s know about them here:
Some of the benefits of cashless claim settlement process are:
In cashless claim settlement, there is no need to pay hospital bills by the person insured. This removes the burden of arranging finances. If the policyholder is admitted due to certain emergency, arranging finances can be difficult at times. With cashless facility, one can concentrate on recovery without having to worry about the financial side as the policy provider will take care of it.
Moreover, this process is fast since the insurance companies already have a fixed process for handling such issues in-network hospitals. Hence, time is not a constrain. It requires less time in validating the health insurance claim.
Also, there is no need to keep track of hospital bill payments once the claim is approved.
However, it comes with disadvantages as well. If one's preferred hospital is not in the list of network hospitals, then the cashless claim option won't be available. The person insured will have to opt for a reimbursement claim process. That's why it is often suggested to opt for an insurer which has a tie-up with one's preferred hospital.
The main advantage of the claim reimbursement process is that one doesn't need to act immediately. In case of emergency hospitalisation, the person insured may not be in a condition to reach the network hospital, the claim reimbursement process allows a policyholder to get admitted to any hospital near to them without worrying about claim settlement issues. In such cases, the policyholder needs to pay the amount which later gets reimbursed.
Unlike cashless hospitalisation, the claim reimbursement process is tedious. One will have to keep the original copies of all the bills and other relevant documents which are to be submitted to the insurance company for validating the claim. Since the process for reimbursement is an elaborate one, the time required to settle claims is also more. One will also need to keep track of the claim status with the hospital and insurance company for getting the reimbursement. Also, arranging finances could be a problem too.
Health insurance is very important. However, to ensure that the policy provides maximum benefit, one must be aware of the policy terms in detail. An understanding of the inclusions and exclusions will help a person to avoid any last-minute issues. And above all, one must be aware of the claim steps to be followed to avail these benefits.
Ans: A claim settlement ratio is the number of total claims settled in a year divided by the total number of claims received. It tells about the efficiency with which a company settles the claims made.
Ans: Claims are rejected due to the following reasons:-
There can be other reasons for claim rejection which depend on the insurer.
Ans: The inclusions and exclusion can be read on the policy document. Alternatively, one can read them on the official website of the insurer as well.
Ans: A GST of 18% is charged for buying the policy.
Ans: The priority claim settlement is a process in which claims are made within 30 minutes from the time of applying for it.
Ans: A hospitalisation of 24 hours is necessary for a claim.
Ans: Yes, it is possible to claim from two insurance policies if expenses are greater than the sum insured.
Ans: Health insurance companies take 30 to 45 days for health insurance claim settlement.