Types of Health Insurance Claims

There are several types of health insurance claims, each serving a specific purpose. Let's explore some common categories:

• Cashless claims
• Cashless claims are one of the most convenient types of health insurance claims. Here, the policyholder can receive medical treatment at a network hospital without having to pay the entire bill upfront. The insurance company settles the bill directly with the hospital. There might be two cases here: Planned Hospitalisation and Unplanned Hospitalisation. For planned hospitalisation, the insured person must inform the insurer 1-2 days in advance so that the process is taken care of seamlessly. In case of an emergency, it is advisable that the insurance company is informed of the emergency situation within a day of the hospitalisation.
• To make a cashless health insurance claim, a valid government identity card, such as an Aadhaar card or a driving license, is required. Some hospitals may also request ID verification from the policyholder if the patient is a dependent of an employee or the policyholder. Sometimes, hospitals require the policyholder's PAN card, which is normally required when the claim value exceeds Rs 1 lakh.
• Once the TPA verifies the entire documentation, your cashless claims process is settled. However, the process won’t be entirely cashless as you need to cover a few minimal extra charges that are not covered by the policy.
• Pre-hospitalisation and post-hospitalisation claims
• These types of claims cover medical expenses incurred before and after hospitalisation. Pre-hospitalisation claims may include expenses related to diagnostic tests and consultations leading up to hospitalisation. Post-hospitalisation claims cover follow-up treatments and medications after discharge.
• If your whole claim is reimbursed, you may include these expenses when filing your claim. However, if the hospitalisation was cashless, you may have to file this reimbursement claim separately.
• Reimbursement claims
• Reimbursement claims come into play when a policyholder seeks medical treatment at a non-network hospital or opts to pay the medical bills themselves. In this case, the policyholder pays the bills and later submits the relevant documents and bills to the insurance company for reimbursement. The insurance provider evaluates the claim and reimburses the policyholder for the eligible expenses.

While claiming reimbursement, you need to provide all the relevant documents as needed by the insurer. Here is a list of documents that might come in handy for reimbursement of health insurance claims:

• The filled out and signed claim form by the claimer. This form is available online or at the insurance company's office.
• Hospital discharge certificate, summary report, case file, and any other documentation pertaining to your treatment. All of this paperwork must be signed by your case doctor at the hospital.
• All of your original bills, cash memos, and receipts.
• If you received medical treatment because of an accident, you must additionally produce a copy of the First Information Report (FIR) that you filed with the police. If no FIR is available, you must offer a Medico-Legal Certificate.

Once all your documents are processed and found to be true, the insurance company will reimburse all your medical expenses that are covered under the policy.

It is of immense importance to choose a reliable and well-known health insurance provider when it comes to availing a policy. Here are a few factors you must consider before choosing the right health insurance company for yourself.

• Select the company that has tie-ups with an expansive network of hospitals so that you can avail of the health insurance facility in the best healthcare centres.
• Avoid companies that exponentially increase premium rates once a claim is made.
• Choose the health insurance company that offers convenience when it comes to claim settlement.
• Choose the company with a higher insurance Claim Settlement Ratio (CSR). It is the percentage of claims that an insurance provider pays against the number of claims made in a given fiscal year.

It is of immense importance to buy health insurance, and here are some of the vital reasons regarding the same:

• Due to the rise in the cost of healthcare services, it is a necessity to buy a health insurance policy if you don't want to dip into your savings during medical emergencies.
• You can get both yourself and your entire family covered under a health insurance policy.
• It is a smart thing to get your medicine, test bills, and doctor consultation fees covered by a health insurance policy as, although they seem like one-time expenses, they can slowly add up and put a dent in your pocket.

It should be noted that even if you are covered under an employee health insurance policy, it is ideal to purchase an individual policy as the employee plan will cease to exist once you retire.