How to avoid surprises in a health insurance claim process?

• Introduction
• Steps you should take as soon as you realize a hospitalization is required
• Two types of claim settlement processes
  • Cashless Claim Process
  • Reimbursement Claim Process

A health insurance claim, whether through a cashless facility or a reimbursement process can be very technical and tedious. This article will help you with all the necessary information and hacks so you understand the entire process well and don't face deductions or rejections for a minor mistake or lack of paperwork.

Before we understand, the step by step process, let's understand the two key ways health insurance can be claimed:

1. Cashless facility, through the hospital

This is a super convenient process for you, as it saves you the trouble of tedious paperwork or paying cash upfront. Having said that, you might need to run around a little and coordinate between the hospital and the insurance company, while your family is admitted and getting treatment. For a cashless claim settlement in insurance, the hospital you choose should be on the insurer’s approved list of cashless hospitals, for this type of claim settlement.

2. A reimbursement claim, directly with the insurer

In this type, you pay the hospital costs upfront, and later claim the amount from the insurer. In this process, you will have to do a majority of the paperwork and submit it directly to the insurer. This happens, when the hospital where you’re taking treatment is not on the insurers approved list of hospitals.

The health insurance claim settlement process

Here’s a typical health insurance claim journey, you will go through.

The process is explained in detail, in the paragraphs below.

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Choosing the hospital:

Mostly, you’ll want to take treatment at a hospital recommended by your doctor, where they would be available. First off, check if that hospital has a cashless arrangement with your insurance company.

• If you have the flexibility to choose across hospitals, go through the latest list of cashless hospitals on your insurer’s website.

Choosing the Room Category

Health insurance policies often have a room rent limit or category limits. As far as possible, try and choose a hospital room within these limits so you don’t have to pay huge amounts out of pocket.

• Ask your hospital for an estimate of the total treatment cost, including the room rents.
• Check your policy document and confirm which room rent limit is applicable and make a decision accordingly. Remember, if you choose a higher cost room/ category - you might need to bear a proportionate cost of most of the other expenses billed as well (in addition to paying the room cost difference). This can easily build up into a major cost (even 50% of your bill amount), so be careful.
• If you have multiple health insurance policies, check if you can include policies that don't have room rent limits first.

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Once you choose the hospital and the bed category, you will have to go through one of the two types of claim settlement processes - either cashless or reimbursement.

Here’s a detailed insight into both of them.

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1. Reconfirm with the hospital desk about the cashless cover with the insurance provider.

• These hospital-insurer arrangements are very dynamic and often change. You do not want to make a decision and then realise the hospital doesn’t have the tie-up.
• Note that some hospitals may have different arrangements for corporate policies and personal insurance policies - be aware of this difference and ask them clearly. It would be best, if you could carry a copy of your policy and take their confirmation of the same.
• Once this is done, ask the hospital desk for a checklist of all the documents they will need from you for a smooth process.
• Further, check for any sub-limits for specific ailments in your policy - this will help you get visibility of how much you will be paying from your pocket.

2. First Approval/Pre-Authorization

During the pre-authorization step, the hospital (on behalf of you) will request the insurance company to make an initial approval of your treatment cost.

• You’ll need to inform the insurance desk at the hospital about the policy you hold, and submit any documents they might demand.
• You will be asked to fill up and sign a claims form at this stage. A part of this form is then filled by the doctor/hospital staff.
• The insurance desk will take the process ahead with the TPA or the insurance company.

3. Need for Advance/Deposit in Cashless

• While your insurance company’s call center might be working 24x7, the hospital’s insurance desk might not . They usually close at 7pm everyday and have a weekly Sunday off. So, depending on these circumstances you might need to pay an advance to get the admission, or delay the discharge if the final approval is delayed. Some hospitals may ask for deposit, albeit smaller, even in cases where cashless is approved. **Always keep emergency money handy or an active credit for such situations. **
• In case the treatment cannot wait for the pre-authorization approval, the hospital might ask you to make an advance payment. This advance is later refunded (fully or partially) when the insurance company approves the cashless claim request.

4. Documents you need to have handy

1. Policy copy or cashless card
2. All past medical records leading to the hospitalization
3. KYC for the patient
4. Police FIR (in accidents)

5. Here's what you should take care of in a cashless claims process

• Process the paper work in advance: In case of a planned hospitalisation, submit the form at least 3-4 days before admission. If this is not possible, arrive at the hospital one hour ahead of the patient and finish the paperwork. If you are the patient, send in a responsible family member to complete the paperwork before you get to the hospital, and prevent avoidable delays.
• In case of emergency hospitalisation, submit the form within 24 hours of hospitalisation
• Track progress: Once you are done submitting the pre-authorization form, you should be able to track progress on the TPA app or website. Do this diligently. Ensure all queries raised by insurance companies are answered at the earliest, which will ensure the claim settlement is not disrupted or delayed. An insurance company can cancel an authorization provided for not submitting answers or documents for their queries. In this case you may have to go for reimbursement then.
• Keep copies of all documents submitted: The insurance company might ask for original copies of bills and other documents. Ensure that you have a soft-copy (or at least photocopies) of every document you submit, as it would be close to impossible to get them later.
• Track the billing everyday: Check the hospital bills everyday so you find and fix any errors or discrepancies that might creep in. With a fair picture of how much the final bills might be, you can then either inform the insurer of any additional charges, or use another policy if the coverage is not sufficient.
• Record keeping of all pre-hospitalization expenses: Medical expenses incurred prior to hospitalization will not be cashless - and have to be claimed separately with the insurer. While you go through the treatment, store all the original prescriptions, bills/receipts, reports (including films) that led to the hospitalization, since these can be claimed separately. It is important to have prescriptions from the first doctor you visited, with a complaint leading to this hospitalization also handy, especially if they’re from another place/ not your family doctor.
• Give priority to cashless expense: You can choose to purchase medications at the hospital counter, before discharge as well, as they would get covered under cashless as well.

6. Final Billing

Once the discharge date is finalized by the doctor, follow up with the hospital insurance desk to submit all your final paperwork including the final bill and discharge summary to the insurance company.

• This can take some time, so you must initiate this process as early as possible.
• At this stage, if any documents are pending, the insurance company would notify you. Keep track of the progress through the insurance company's online tracker, and submit any missing documents at the earliest.
• The final approval of your cashless claim is necessary for the cashless facility to be continued. It usually takes between 2 to 6 hours to receive an approval from the insurer once all the papers are submitted.
• In case the final approval does not arrive or is delayed, you may have to keep the patient waiting at the hospital or pay upfront and claim the amount later as reimbursement. Be prepared for this.

7. Claim Approval

Most important part where you need to give your full attention

• The final communication for approval or decline in the form of a claim settlement summary, will provide all details of the claim settlement.
• Approved claims will show an account of the expenses approved and unapproved as per the terms and conditions of your insurance plan.
• You must read through the claim settlement summary carefully to get a hang of what did not get approved, and whether these additional expenses are to be paid by the user’s account.
• You might have to pay for expenses not paid by the insurer such as co-payment, proportionate deduction, exclusion for consumables, etc. Don’t forget to get your initial advance adjusted in this calculation. .
• Hospitals may keep some deposit with them beyond discharge as retention money till they receive their payout from the insurance company. Ensure you store this receipt and put a reminder for collecting this refund in a couple of months.
• If your claim had deductions due to shortage of the available sum insured or limits/exclusions or co-pays in the policy, you can claim the remaining amount from another health insurance policy on a reimbursement basis.
• Every cashless claim has a reimbursement component - for pre-hospitalization and post-hospitalization expenses. Do not forget to make a claim for these expenses.

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Even though the reimbursement process only happens after your treatment and discharge, you should be wary of the things to do even before and during hospitalization.

Reimbursement can be for a) The entire treatment - right from pre-hospitalization till post-hospitalization or b) In case of cashless it can be for only pre and post-hospitalization expenses, which cannot be cashless. c) When one policy is used for cashless claim and the remaining unclaimed amount is claimed through reimbursement.

1. Claim intimation

Intimation or registration of a claim is the first step. As far as possible, call up/email the insurance company and inform them about the hospitalization within 24 hours of the admission.

• Also, ask them about the timeframe during which you can submit the reimbursement claim after discharge, so you know your deadlines.
• Take a check-list of all the documents you will need to submit for a successful claim, and start putting them together.

2. Collecting and maintaining the documents

The reimbursement entirely depends on your documentation and record keeping. From the date of discovery, to the period or recovery - ensure that all documentation is collected and maintained.

• Include all documents of doctor consultations, prescriptions, bills, receipts, reports (including films), X Ray or MRI films to pharmacy bills and everything else in a secure folder.
• Create an excel sheet of all the medical expenses starting from the first doctor consultation to all the medical tests, hospital bills, medical test reports, all doctor prescriptions after discharge, receipts, medicine bills throughout.
• Organize and number these documents for ease of handling and submitting them later on.
• Fill up the claim form carefully after reading what is asked and providing all the details correctly

3. Documents required for Reimbursement Claim

• Health card or policy copy.
• Photo ID of the insured
• Claim form - filled and signed. (A part of this form has to be filled by the hospital with the treating doctor’s sign)
• All prescriptions for medicines, medical tests including prescriptions from the first doctor you visited, with a complaint leading to this hospitalization (it is important to have those documents handy, especially if they’re from another place/ not your family doctor) in original
• All pharmacy bills in original
• All test reports, including films & CDs (Xray, MRI) in original
• Hospital bill with patient details including itemized bill, in original
• Discharge summary from the hospital in original
• All other original bills before the hospitalization associated with your treatment. (The bills for expenses after the hospitalization can be claimed separately after 60 days or the stipulated time in the policy)
• Bank account details of the policyholder which can be provided through a cancelled cheque for NEFT transfer of your reimbursement. Insurers do not send cheques, they only make online transfers.
• FIR or a medico-legal certificate or a summary of how the accident happened may be required in case of an accident.

4. Make a carbon copy of all the original documents you submit to the insurer, and retain them for your own record.

Queries

• Insurance company may raise queries or request for additional requirements. Ensure you track the claim status on the insurance company's portal or app regularly to know of such requirements and address them at the earliest.

5. Settlement

• Insurance company usually credits the amount in the bank account you provided while submitting your claim.
• They will send communication on the settlement with a summary of deductions made.
• You must go through these in detail to ensure you have understood all the deductions well.
• You can raise a query with the insurance company in case you have any doubts.

We've tried to put all our learnings regarding claim settlement in a single document.

Hope it helps you tread past this tedious and complicated process. You can always reach out to us to share your experience or in case of any questions on the Beshak Insurance Forum.