Cashless Claim Process:
In order to avail the cashless claim facility, the insured has to be treated in an empanelled hospital. By providing the details of the health insurance policy and presenting the e-card or other physical proof of the health insurance taken in the name of the policyholder, he or she can avail cashless hospitalization and treatment, if the illness/ injury is covered under the policy. Once the patient is discharged from the hospital, all the medical bills are sent to the insurance provider by the hospital. The insurance provider then evaluates the expenses and settles the payment.
The claims process for treatment at a cashless network hospital varies according to the type of treatment – Planned or Unplanned. Unplanned medical treatment at a cashless network hospital usually happens in case of an emergency.
- Claims Process for Planned Treatment at the Cashless Network:
Usually, the insured has to inform the insurance provider of the hospitalization or treatment requirement ahead of time in order to avail cashless treatment. The company should be informed at least 4 days before the treatment date. A cashless claim request form should be submitted at the relevant address of the insurance provider – mostly via post, e-mail, or fax. For more information you can contact the customer care of your health insurance provider. Once these steps are completed, the insurance provider will notify the insured as well as the concerned hospital regarding the policy cover and eligibility. On the day of admission in the hospital, the policyholder has to display his/her health insurance card and the confirmation letter. The medical bills will be paid by the insurance provider, directly to the hospital.
- Claims Process for Emergency Treatment at the Cashless Network:
The policyholder can contact the customer care help desk of an insurance provider in order to get information about the nearest network hospital. By displaying your health insurance card, you can avail cashless hospitalization. The hospital has to fill in the cashless claim request form and submit it at the relevant address of the insurance provider – mostly via post, e-mail, fax or through customer care. An Authorization Letter will then be issued by the insurance provider to the hospital, indicating the policy coverage. The medical bills will be paid by the insurance provider, directly to the hospital. In case of rejection of the claim, a letter will be sent to the insured, stating the reasons for rejection.
Reimbursement Claim Process:
The reimbursement claim for health insurance can be made if the policyholder opts to go to a hospital of his/ her choice, which is a non-empanelled hospital. In this case, the cashless claim facility cannot be used. Therefore, the insured has to pay all his/ her medical bills and other costs involved in hospitalization and treatment and then claim reimbursement. In order to avail reimbursement claim you have to provide the necessary documents including original bills to the insurance provider. The company will then evaluate the claim to see its scope under the policy cover and then makes a payment to the insured. In case the treatment is not covered under the policy, the claim will be rejected. The insurance provider generally provides reasons for the rejection.
The following documents are required in order to make a health insurance claim:
- Duly filled claim form
- Medical Certificate/ Form which is signed by the treating doctor.
- Discharge summary or card (original), availed from the hospital.
- All bills and receipts (original)
- Prescription and cash memos from pharmacies/ the hospital.
- Investigation report
- If it is an accident case, then the FIR or Medico Legal Certificate (MLC) is required.