Most Important Tips On Claim Settlement In Health Insurance


Every financially-prudent individual understands the importance of investing in a health insurance policy for securing their own future and that of their loved ones. After all, one can be as cautious and careful about one’s well-being, yet health problems can come knocking regardless of the number of hours spent working out or eating nutritious foods.

However, just buying an insurance policy isn’t enough anymore and securing your financial future against medical bills goes beyond that. You also need to understand how the insurance claims process works so that when you actually do need to fall back on the policy, you don’t have to run from pillar to post to make sure that the insurer bears the cost of hospitalization and other expenses.

So here’s a lowdown on the critical aspects of health insurance claims that every smart policy buyer should know about, for added peace of mind:

1. Understand what your policy covers: The first and foremost aspect of your health insurance plan that you need to be aware of is what all your policy covers and what is it that you can actually claim. Be familiar with the hospitals within the network of your insurer as you can enjoy cashless facilities only at these hospitals. You need to also be aware of the treatments that are covered by your health insurance and not work under assumptions. Further, you must have a clear view of your health insurance sum insured and if the doctor gives you an inclination that your treatment costs will be above that, then you need to tap other financial sources to meet your medical expenses at the earliest.

2. Proper documentation: While the cashless facility means that the insurer pays the hospital directly on your behalf, in case you need to claim reimbursement, things start to get tricky. The primary facet that you need to get in order is all the documentation related to your medical costs and procedures. Insurers often reject claims because patients or their families are unable to furnish the right legal and expense related documents pertaining to the treatment. As and when the medical process begins, make one consolidated file of all your papers that you can present to the insurer so that there is no scope for claims rejection.

Some of the common documents that you need to have in place include the claim form duly filled, discharge summary, doctor’s prescriptions with complete medical history, all the bills, all original receipts, investigation reports and FIR in case the hospitalization happened due to an accident. In case the hospital where you had to be admitted in an emergency doesn’t fall in the network of the insurer, you may also have to get the hospital and doctor’s registration number written signed and stamped on the hospital’s letterhead.

3. Timeliness: Yes, in the case of a medical emergency, informing your insurer may be the last thing on your mind, but it is imperative. It is necessary that you have an open discussion with your family members about the same and keep them informed about who your insurer is and how one can inform the company in case of an unplanned hospitalization. If there is a delay of more than 30 days from the day of being discharged, in informing the insurer, it can lead to a financial tussle for your family. In case of a planned hospitalization and to avail the cashless facility, fill up all necessary forms at a preferred network hospital at least seven days in advance to have a smooth experience.

4. Timelines: Another important point to note is that as per the Insurance Regulatory and Development Authority of India (IRDAI), the insurer must settle reimbursement claims within 30 days from the day that you submit all necessary documents. As a responsible and intelligent consumer, you must also know that the insurance company is liable to pay you interest of 2% above bank rate for every successive day after the submission of all documents till you receive the reimbursement. The insurer may also look at an investigation before settling all claims. This investigation has to be initiated within 30 days from the date of document submission and should ideally be wound up within 45 days.

Today, the insurance industry is highly consumer-driven and players in this realm are well-aware that customers opt for a plan not on the basis of the most affordable premium, but on the basis of the best experience offered and the track record of an insurer in settling claims. Every company, therefore, is pulling out all the stops to make the claim settlement process as seamless as possible. However, as a customer, one must ensure that one is familiar and aware of all the fine print in one’s policy and is completely diligent in terms of paperwork so that there is no scope for any discrepancy or stress at a stage when the focus should just be the well-being and recuperation of the patient

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