+91-98111-67809How to File a Claim & What Is the Process?
How to File a Claim & What Is the Process?
Table of Contents
- How to File a Claim & What Is the Process?
- Get Expert Advice
- Get Expert Advice
- Cashless:
- Documents Related to the Cashless Claim Process
- Pre-Authorization:
- Reimbursement
- Documents for the Reimbursement Claim Process
- Pre & Post Hospitalization Claim
- IRDAI Guidelines for the Better Cashless Claims
- Scope of Coverage Will Increase:
- Instructions for an Easy and Quick Pre-Authorization Medical Claim:
- Step 1: Locate the Closest Network Hospital
- Step 2: Verification
- Step 3: Approval Received
- Related Posts
- FAQs
How to File a Claim & What Is the Process?
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Get Expert Advice
Get Expert Advice
Get Expert Advice
There are many queries about the claim process in the country, such as how to apply for a claim. Who should we approach? What is the claim process?
Here are all of your responses:
So there are two types of claim processes. I.e_._ cashless and reimbursement
Cashless:
As the name implies cashless means that no cash is required for the claim (Although the policyholder must pay File charges, etc. and the claim is paid up to SI).
An insurance company has affiliations with hospitals. A policyholder can go to the nearest network hospital for cashless treatment. The list of network hospitals is updated on the insurance company’s website.
Let’s break it down: Hospitals have agreements with insurance companies. A policyholder can seek cashless care at the nearest network hospital; the list of network hospitals is updated on the insurance company’s website. The hospital is paid directly by the insurance company for treatment costs and medical expenses. Always choose cashless care at your preferred network hospital, and always consult the network hospital list for the best and quickest treatment by your doctor.
Documents Related to the Cashless Claim Process
While claiming treatment at your nearest network hospital, there are T.P.A desks (Third Party Administrators, whose job is to coordinate with the customer, hospital, and company. all at the same time).
Documents for further process.
Like,
i_) Health Insurance policy / Health Cards._
ii) I.D Proof related Document.
iii) Date of Birth proof Document.
iv) Doctor’s prescription.
Pre-Authorization:
Another method for starting the patient’s treatment through the claim
So, how exactly does it work?
You already know what treatment or surgery will be performed! In this case, your first step is to notify the insurance company about the treatment and the doctor at the policy company’s network hospital. After reviewing the medical documents, the claim is generated. The doctor will provide the policy company with a detailed prescription for the treatment as well as the estimated cost of the treatment, and the policy company will approve the pre-authorization claim after cross-checking the related documents
Reimbursement
Reimbursement means, the policyholder is paying for the treatment by himself/herself and then files a claim with the help of bills of the treatment which was paid during the treatment.
Documents for the Reimbursement Claim Process
When filing a claim, you must provide certain supporting documentation. There are two methods for filing a claim offline and online.
Nowadays, most companies work digitally, and to apply online, simply visit the company’s website or application and follow their guidelines, while to apply offline, you have to submit documents physically, and simply organize a file with the necessary documents. Like
i) Original Documents
You should carry all the original documents which were used for the treatment like diagnosis reports, discharge Summary, bills/receipts, and medical reports/tests.
ii) KYC document.
iii) Identity card
iv) Cancel cheque
Pre & Post Hospitalization Claim
There are two important terms, you should understand before getting your insurance, pre-hospitalization expenses and post-hospitalization expenses. If you have been admitted to the hospital for a medical illness following which, you file a claim which was approved by the insurer then all the diagnostics and medical expenses done by the patient before being hospitalized are called pre-hospitalization expenses.
Further, when you get finally discharged from the hospital the cost of medicine, test, and doctor fees for follow-up treatments are termed post-hospitalization expenses. When you file a claim for medical expenses most health insurers will cover the pre-hospitalization and post-hospitalization expenses in the claim, however, these expenses are covered for a certain number of days only, which is mentioned in the policy document
IRDAI Guidelines for the Better Cashless Claims
IRDAI has always been working for policyholders and companies to help them in giving better and easy services. IRDAI has better a step ahead for the policyholders in their new guidelines on 20th July 2022. It was termed as cashless hospitalization through a preferred partner network. What all does IRDAI’s new guidelines covers?
Scope of Coverage Will Increase:
The scope of coverage of policies has been increased across the length and breadth of the country. It has been stated that the list of cashless network hospitals will increase and following the quality control of the same will be better for the claim process and treatment. Here insurance company must set up some quality checklist criteria so it will also help in tying up with more hospitals that provide a better quality experience and services to the policyholder.
Some benchmark setup by IRDAI that every network hospital should follow like
- Minimum Manpower
- Minimum Infrastructure Requirement
Hence it all will provide better and hassle-free cashless claims and ease for the policyholder!
Instructions for an Easy and Quick Pre-Authorization Medical Claim:
In India, the cashless claim process is used to pay for various services at hospitals, and once the patient arrives at the hospital and requests assistance, the hospital is required by policy to begin treatment as soon as possible. {Although, the Policy Company will approve or reject the claim and provide a pre-authorization letter (if approved) for the patient}.
But first, the Customer must submit his/her/patient’s details for approval. As you are aware, there are two types of claim processes: cashless and reimbursement claims. We’ll go over every step of the claim process here.
Step 1: Locate the Closest Network Hospital
The process begins when the customer arrives at the network hospital for cashless treatment of the patient to provide better care and treatment (although the hospital could be a network hospital or another hospital that is not listed in the policy company).
The customer must complete a claim form and provide all necessary documents before proceeding with the procedure. The following documents are required for the claim:
i) Health Insurance policy / Health Cards.
ii) Identification Proof Document. (Aadhar card/Voter ID card)
iii) Proof of Date of Birth Document. (Aadhar card*)
iv) Doctor’s prescription.
Step 2: Verification
Once you have submitted the necessary documents for the claim, you must wait for approval from the insurance company.
The hospital will check the customer’s information and send the duly completed pre-authorization form to the insurance company. Once verified with policy benefits, the insurance company sends an authorization letter back to the network hospital. (Depending on the terms and conditions of the individual company, the pre-authorized request may take up to 2 to 4 hours.)
Step 3: Approval Received
Once the pre-authorization is authorized and received by the network hospital, the hospital begins treating the patient without any expense until discharge, it may alter depending on the terms and conditions of the insurance or the different companies. The policyholder is mandated to pay File charges, and the claim is paid up to SI. Treatment charges and medical expenditures are paid directly by the insurance company to the hospital (try to pick cashless treatment in your closest or preferred hospital for a hassle-free claim)
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FAQs
How Do I File a Cashless Claim for Medical Treatment?
To file a cashless claim, visit a network hospital affiliated with your insurance company. Submit the required documents, including your health insurance policy, ID proof, date of birth proof, and doctor’s prescription. The hospital will coordinate with the insurance company to generate a pre-authorization claim. Once approved, the insurance company will directly cover the treatment costs at the network hospital.
What Documents Are Necessary When Filing a Cashless Claim at a Network Hospital?
To file a cashless claim, you need to provide documents such as your health insurance policy/health card, ID proof, date of birth proof, and the doctor’s prescription. These documents help facilitate the pre-authorization process for your treatment.
How to File a Reimbursement Claim?
To file a reimbursement claim, you pay for the medical treatment yourself and collect bills and receipts. You can submit the claim either online through the insurance company’s website or offline by physically submitting the necessary documents. Required documents include original documents related to the treatment, KYC documents, identity card, and a canceled cheque.
What Are Pre and Post Hospitalization Claims?
Pre-hospitalization expenses are the costs incurred by the patient before being hospitalized for a medical condition, and post-hospitalization expenses cover medical expenses, such as medicine, tests, and doctor’s fees, after discharge from the hospital. Most health insurers include coverage for these expenses, but there is usually a limit on the number of days for which they are covered, as mentioned in the policy document.
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