How to file a Health Insurance Claim
Steps you will need to follow to file a Health Insurance claim with your Insurance company. This article is intended for a person wishing to file a claim after treatment has been provided.
Things You'll Need
- Claim Form duly filled and signed by the claimant
- Discharge Certificate from the hospital
- All documents pertaining to the illness starting from the date it was first detected i.e. Doctor's consultation reports/history
- Bills, Receipts, Cash Memos from hospital supported by proper prescription
- Receipt and diagnostic test report supported by a note from the attending medical practitioner/surgeon justifying such diagnostics.
- Surgeon's certificate stating the nature of the operation performed and surgeon's bill and receipt
- Attending doctor's / consultant's / specialist's / anesthetist's bill and receipt, and certificate regarding diagnosis
- Certificate from the attending medical practitioner / surgeon that the patient is fully cured
- Details of previous policies if the details are not already with TPA except in the case of accidents
Address of TPA where all claim documentation should be sent
Steps
For a Planned Hospitalization contact the Third-Party Administrator (TPA) for your Health Insurance Policy and inform them of the planned hospitalization. Also verify the coverage terms of your policy and ensure that the Hospital/Medical Facility where you are planning to get treatment is in the Insurance company's Network. In case of a hospital that is not in the network understand what costs will be covered. If your Insurance company offers cash-less facility then ask the TPA about the process to follow.
In case of an Unplanned Hospitalization inform the TPA as soon as possible to get the Claim forms and understand the procedures for filing a claim. Please keep in mind that your claim form and all supporting documents should be filed within 7 days of completion of treatment.
Once treatment is complete get all the necessary documentation from the hospital and surgeon. You will have to settle all bills out of your own pocket and get reimbursed by the Insurance company. Check your policy to understand where pre and post-hospitalization expenses are also covered. In this case all documentation for these expenses should also be filed. Complete the Claim form, attach all supporting documentation and mail/fax to the TPA. Keep a copy of all documents for your record. The insured must also provide the company/TPA with additional information and assistance as may be required by the company/TPA in dealing with the claim. It is in your own interest to call the contact person at the TPA on a regular basis to ensure proper processing of your claim.
Reimbursement of your Claim - In certain cases your claim maybe rejected if the treatment is not covered by your Health Insurance policy. If your claim is denied make sure you write to the Insurance company within 15 days to lodge a complaint.
In case of partial payments, check with your TPA for the reason for partial payments. In most cases providing additional documentation might help recover the rest of your claim.
Tips
In case of a claim being rejected the insured person may file a complaint with the Insurance Ombudsman who is an arbitrator appointed by the Insurance Regulatory Development Authority. The Ombudsman can very well decide that your claim is legitimate and decide in your favor.
Caution
- Make sure that all required documentation is complete when submitting your claim.
- Ensure that you file a claim within 7 days of completion of treatment.
- In case of a rejection of your claim file a protest with the Insurance company within 15 days.
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Comments
Can an insurance plan cover
Can an insurance plan cover the need for rehab? I'm curious because dependency is a disease as well...
This is great information.
This is great information. What is covered or not is a totally different story. I believe that depends on your insurance plan.
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