Steps to sail through health claims

Opt for cashless settlement of dues, make full disclosure and retain relevant records

When faced with the trauma of admitting a family member to the hospital for a surgery or an in-patient treatment, the last thing you want is a delay in claim settlement or, worse, denial of hospitalisation expenses from your insurance company.

To make your claim process smooth, you need to follow a few steps diligently, so that all your legitimate dues are settled.

Be upfront on disclosures

Non-disclosure of previous illnesses and lifestyle activities is a key reason for rejection of claims. While applying for your health insurance policy itself, you must come clean on all aspects related to your health. You must make complete disclosures if you are a regular smoker and frequently consume alcohol.

Also, you have to give details of any existing health conditions or ailments that you have. For example, details of sugar levels, high blood pressure, heart conditions and any history of serious ailments or surgeries need to be disclosed.

If you make these disclosures, your premium would be suitably fixed by the insurer by taking all these risk factors into account, and chances of claims rejection will be lower.

The insurer must be convinced that the claim is not related to a disease that is traceable to any pre-existing conditions or lifestyle choices.

Opt for cashless treatment

If your family member’s treatment or surgery is a planned one, identify a network hospital where your insurer offers cashless settlement of claims. Inform your insurer about the surgery or treatment at least seven days before admission and get the necessary approvals. This way, you will be aware of any ceiling in amounts that can be released for specific ailments.

One the other hand, if you are admitting a person for unplanned or sudden illness, you can still stay prepared to some extent. For starters, always keep a list of network hospitals that are near the insured’s workplace, home, cities that are frequently visited on travel etc. It is good to carry your insurance card or a copy of it with you at all times.

But in case of dire emergencies, you can go to a non-network hospital; you will have to spend from your pocket and claim reimbursement later.

If admission is for unplanned treatment or for emergencies, inform your insurer within 24 hours of admitting the patient.

Awareness and documentation

Being aware of the waiting period for some illnesses and the exclusions is very important as a policyholder. That way, you will be fully aware and would be able to make claims only in legitimate cases. Also, you must know the sub-limits on rooms and other cost heads.

 

Once the treatment is over, you should get all the relevant documents from the hospital. These include the discharge summary, doctor prescriptions, pharmacy bills, medical tests and all records relating to the ailment.

If you are successful in opting for cashless service, the documents would automatically be sent to the insurer by the hospital. But you must retain a copy of the documents with you for reference and any future follow-up.

In case you opt for reimbursement, documentation becomes all the more important and you must take special care in having all the relevant papers intact.

All settlements are to be done by the insurer within 30 days of making the claim with the relevant documents, as mandated by the insurance regulator.

Emergency cash, timely renewals

There may be cases where you need to co-pay for claims, especially when the patient is a senior citizen. So, you must have 10-15 per cent of the estimated cost of the surgery or treatment ready so that you have smooth claim settlement for the balance portion.

If you build an emergency kitty over a period of time that is equivalent to about six months’ total expenses, you can easily sail through with the payment requirement. Having an emergency corpus is also useful if you have to take the reimbursement route to settle medical bills.

Finally, renew your health insurance on time, preferably a week or so before it expires, so that you have a live policy at all times. If the policy lapses, even for a day, you will not get coverage.

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