Niva Bupa Health Insurance Claims Procedure

The following are the two types of claim settlement options: 

Cashless Claim Settlement Option:

A practical and typical option, cashless claim settlement is provided by many hospitals and health insurance companies. Policyholders are able to receive medical care at network hospitals without having to pay the full cost of the service in advance. Instead, the insurance provider pays the hospital directly on the policyholder's behalf, up to the policy's coverage maximum. It is simpler for policyholders to receive critical medical care because they do not need to make substantial upfront financial arrangements. The following are the ways on how it works: 

1. A hospital that is a part of the insurance provider's network of medical facilities is where policyholders must go. To enable cashless claims, these network hospitals have a partnership with the insurance provider. 
2. The policyholder or the hospital must get in touch with the insurance provider to get pre-authorization for the medical costs prior to receiving treatment or being admitted to the hospital. This includes disclosing specifics about the ailment, the suggested course of action, and a projected cost estimate. 

1. The insurance provider examines the pre-authorization request to make sure the requested therapy is covered by the terms of the policy and that it satisfies the requirements for medical necessity. The insurance provider sends the hospital an authorization letter when it has been granted. 
2. The policyholder can access the required medical care at the network hospital with the authorization letter in hand. The insurance provider is billed directly throughout this process; the policyholder is not responsible for paying the covered costs. 
3. After the procedure is over, the hospital bills the insurance provider for payment. Up to the sum insured or coverage limit stated in the policy, the insurance company pays the hospital's expenditures directly. 

1. The policyholder may still be responsible for any deductibles, co-payments, or non-covered charges according to the terms of the policy even though the cashless facility covers the insured medical expenses. The insured will be responsible for paying these sums, if any. 
2. It's crucial for the policyholder to save copies of any pertinent paperwork, like as the authorization letter, invoices, and medical records, for future reference or in the event of a dispute. 

Reimbursement Claim Settlement Option:

Reimbursement claim settlement is a health insurance procedure in which the policyholder pays for their out-of-pocket medical expenses and then submits a reimbursement request to the insurance provider. When a policyholder obtains medical care at a hospital or healthcare facility that is not in the network, or in situations when cashless claim settlement is not offered or not preferred, this technique is used. The following are the ways on how it works: 

1. The insurance company's network may or may not include the hospital or healthcare facility of the policyholder's choice for receiving medical care. 
2. The policyholder pays the medical bills at the time of treatment or after discharge and gathers all required invoices, receipts, and medical records relating to the treatment. You must save these records in order to submit a compensation claim. 
3. The policyholder must file a reimbursement claim to the insurance provider after obtaining the treatment and paying the associated expenses. This normally entails completing a claim form that the insurance provides and attaching all necessary evidence, such as prescriptions, medical bills, invoices, and other pertinent paperwork. 

1. The insurance provider looks over the reimbursement claim to make sure the costs are covered by the terms and conditions of the policy. Additionally, they confirm that the costs were fair and usual and that the therapy was medically necessary. 
2. The insurance provider handles the payment once the claim is accepted. Based on the conditions of the policy's coverage and the proof supplied by the policyholder, they determine the amount to be refunded. The policyholder normally receives the compensation via cheque or electronic funds transfer. 
3. According to the conditions of the policy, policyholders may still be liable for any deductibles, copayments, or non-covered charges. After taking into consideration these variables, reimbursement will be given for the eligible expenses. 

1. Policyholders must keep copies of all claim-related paperwork, including the claim form, bills, invoices, and medical records, as these may be required for reference or as evidence in disagreements. 

What are the Documents Required for Claim Settlement Process? 

You have to submit the following documents for claim settlement process: 

1. Duly filled and signed claim application form 
2. Treatment papers 

1. Doctor’s prescription 
2. Diagnostics report 
3. Invoice of medicines purchased 
4. Medical discharge certificate 
5. Scanned copy of your health card 

1. FIR copy in case of an accidental emergency 
2. Cancelled cheque 
3. Doctor’s certificate with diagnosis 
4. Know Your Customer (KYC) documents 
5. Certificate issued by attending doctors 

1. Relevant diagnosis reports

How to Check Health Insurance Policy Claim Status? 

To make sure that your claim is being processed accurately and promptly, it is crucial to check the status of your health insurance policy claim. Numerous methods to verify the status of your claim are typically provided by insurance companies. 

Online Process:

The following are the ways to check health insurance policy claim status: 

1. Firstly, visit the official portal of the insurer and login using the credentials. 
2. Once you login, you will be able to check your claim status. 

Offline Process: 

In order to opt for the offline process of tracking the insurance claim settlement, you have to get in touch with the admin department of the insurer. Apart from this, you can also visit the branch directly, and provide all the documents to the branch officials so that they can track the claim settlement status on your behalf. 

What to do If a Claim Gets Rejected? 

You have to follow the given steps if your claim gets rejected: 

Step 1: Know Why Your Claim Was Rejected 

The first and foremost things you need to do is to know why your claim was rejected. Insurance companies might reject claims due to errors in documents or bills. Thus, go through all the documents as well as submitted claim forms and check if there is any error. Apart from this, the insurance provider might think that the hospitalization of the insured is unwarranted. 

Step 2: Get in Touch with your Insurer, TPA (Third Party Administrator), and Hospital 

If you find that you have a genuine reason to reapply for the rejected claim, you can reach out to your insurance company or TPA and let them know about the re-initiation of the claim. You can also challenge the claim-based dispute over email or call. The best idea is to send a written email so that you have proof of communication. Other than this, it is mandatory to get in touch with the hospital authority and mention the details. 

Step 3: Gather the Documents and Proofs 

Depending on the reason on why your claim was rejected, you might have to rectify some information: 

1. If the reason for claim rejection was missing or incorrect documents, you have to correct this by submitting relevant documents having correct details as well as attestation. 
2. If there were any mistakes in your claim form such as your name or the policy number, check them properly and correct them. 
3. If your claim was rejected because the insurance company felt that your hospitalization was unnecessary, you submit your doctor’s prescription or doctor’s letter and pre diagnostic reports to convince the insurer that the treatment was essential to cure the disease you are suffering from. 

Step 4: File the Claim Again 

Once you have gathered all the documents, you have to follow the given steps: 

1. Write a letter to your insurer and TPA mentioning a statement that consists of a reason for your claim being valid as well as correct policy details and policy number. 
2. Next, send this letter to the insurer with proper documents and a statement mentioning the medical suggestion of a licensed practitioner to accept the claim. 

Step 5: Visit the Nearest Ombudsman Office 

If you are not happy with the suggestion provided by your insurance company, you can visit the nearest Ombudsman office within 30 days of getting a response from your health insurer.  

Step 6: File a Case Before the Consumer Court 

In case you are not happy with the Ombudsman, then you can file a case with the consumer court. But you should keep in mind that you might need legal help for which you might end up paying more than your medical bills.