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Insurance Article

Understanding the Claim Game of Health Insurance in India

September 04 2013

A health crisis - It is an emergency that may occur without any signs and symptoms. There's no time to get prepared for the treatment, expenses and making arrangements for various problems that tag along. Then, why not ensure security with a health insurance policy?

It is prudent to choose a right policy for a secure future. So, how to make the right choice? The key is to understand the claim game of health insurancein India.

What is a claim?

To be precise, the term 'claiming' as the process wherein the insured (who buys the insurance policy) approaches the insurer (the insurance company) for reimbursement or direct payment for the health care or medical costs incurred during treatment. This is subjected to the sum insured. The details are mentioned in the health insurance policy.

Medical emergencies need instant attention. Hence, the insured individual must keep their health ID card handy. The card consists of valuable details such as name of the insured, insurer name, period of policy etc.

Claim Intimation
An insurer adopts two ways to process a claim:
1. Cashless Claim Process
2. Reimbursement Claim Process

Cashless claims can be made only under the situations when the treatment is availed in a network hospital. Every insurance company has a network of hospitals where they allow their customers to get treatment without paying cash. Getting treated in one of the hospitals entitles the insured to avail of the cashless benefits. The reimbursement claim process refers to a process wherein the insured gets treatment in a medical facility of his choice, pays for the treatment and then claim for reimbursement of the expenses incurred as per the terms and conditions stated by the insurance policy.

The process of claim intimation in the above stated modes differs slightly:

The Cashless Claim Request

This is only valid for network hospitals. The claim intimation should be completed 48 hours prior to hospitalization. The insurance/TPA desk of hospital faxes a pre-authorization form to the insurance company for proceedings related to the disease and treatment options of a patient. Thereafter, the claim management team sends an approval letter with their suggestion and queries to the hospital. Once these are resolved, the treatment is initiated.

The Reimbursement Claim Request

This is applicable for both for network as well as non-network hospitals. Under this condition, the claim intimation must be done within 24 hours of hospitalization. Here, it is crucial that the insured requires submitting the claim form in conjunction with requisite documents to the insurer, as stated in the policy. The claim management team will offer an approval letter and clear some. Within some time, the insured is informed about the approval.

A methodical and simple to follow health insurance claim procedure allows the insured to avail of the treatment in a timely manner and without any hassles.


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