Health Insurance Claims
Basically there are two types of process in Health Claims – Cashless claims & Reimbursement claims.
- For claim on cashless basis, the insured should get admitted to network hospitals of Third Party Administrator (TPA)/Insurance Company.
- The pre-authorisation form along with necessary documents like investigation report, previous consultation paper (if any),Cashless ID, Photo ID proof, residence proof etc. will be mailed by the hospital to the TPA/Insurance Company.
- The TPA will review the claim request and accordingly approve, query or reject the same as per the policy terms and conditions.
- TPA will settle the claim as per policy terms and conditions with the hospital after completion of necessary formalities.
- For claim on reimbursement basis, the insured should get admitted to any Network/Non Network hospital. The claim should be intimated to the TPA/Insurance Company to get the claim number within stipulated time as per the policy terms and conditions.
- After getting discharged from the hospital, the insured should collect all the original documents from the hospital and submit the same to the TPA/Insurance Company along with the claim form and policy copy within stipulated time as per the policy terms and conditions.
- The TPA/ Insurance Company will review the claim request and accordingly approve, query or reject the same as per the policy terms and conditions.
- For approved cases, Settlement letter is mailed/couriered to the insured/proposer and Payment is released through NEFT/RTGS by the insurance company.
- For queried cases, query letter is sent to the client requesting for additional documents/information. Reminders are sent to the client and if the requested documents are not received after reminders, the claim closure letter is sent to the insured.
- For rejected cases, rejection letter is sent to the insured mentioning sufficient reasons as per the terms and conditions of the policy.
Documents for Claim
- Copy of the policy
- Copy of the Intimation Letter / Mail / Intimation No
- Duly filled & signed claim form
- Original discharge card / Discharge Summary duly signed by treating doctor and with hospital stamp.
- Original hospital bill with break-up details with serial no. duly sealed & signed.
- Original pre-numbered hospital payment receipt duly sealed & signed,
- Original prescriptions,
- Original pharmacy bills (please make sure patient name is mentioned on the bill)
- Original advance paid receipt if any
- Original investigation reports along with original bills & payment receipts for the investigations done within & outside hospitals.
- Original consultation papers, if any
- All Imaging Films, ECG Strips, Doppler / Angiogram CD etc.
- Hospital Registration Certificate (in case of a unknown small hospital)
- Any other original documents related to the claim.
- MLC/FIR in case of Accident cases.
- The copy of the cancelled cheque of the policy holder / Employee in case of corporate client where in claim is payable to employee
- If employee has availed a cashless but if the same is not utilized letter from the hospital mentioning the same.
- Copy of Valid Photo Id Proof of the patient & Policy holder / Employee in case of corporate client.
- Address Proof of Policy holder / Employee in case of corporate client if the claim is more than 1 lakh.
The above is a brief summary of the claims process and documentation, and not to be taken as exhaustive. The surveyor/Insurer/TPA may call for additional requirements on case to case basis.