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5 must-do things for hassle free health insurance claim

By Lovaii Navlakhi, MD & Chief Financial Planner, International Money Matters

A client was recently admitted to the hospital on having shown symptoms of a clot in the brain. As the MRI that was done confirmed this clot, he was taken to the ICU and put on medication to melt the clot.

By the end of Day 2 he was recovering well enough to be told that he would be moving out of the ICU into a private room by Day 4. Day 4 came and went he was not moved. He was feeling pretty normal, his medication had been reduced and he wanted to be with his family, but he was held back under the pretext of observation till Day 7.

Once in the private room, he was told he would be discharged the next day, only to be informed that two specialists had been called in to examine him – but no one came until the next day, Day 8. A Neurosurgeon came and declared he was fine; and a Heart Specialist examined him too but had no clue what he should be checking for, what was the problem/symptoms for which he was called!

It was finally Day 9 when our client walked out of the hospital.

He had insurance – cashless mediclaim, pre-approval for which was taken by the hospital authorities on admission. But they started pressurising the client’s family to pay as the claim settlement would take time since the bill amount had gone up substantially. This was Day 7 when he was moved into a private room. Since the pre-approval was taken and still the hospital was asking for the bill to be settled, the client’s family stuck to their guns and said it is a cashless claim and they will not pay from their pocket. After the specialists left, when the discharge process was initiated, the insurance help desk took Rs.500 to speed it up, but to no avail.

Fed up with this inordinate delay, the client decided to take matters into his own hands. He called the Insurance Claims office and was told that no documents had reached them to process, but was assured him that on receipt of the documents, the claim would be processed immediately. His family then collected all bills and documents from the hospital and faxed to the Insurance Claims office, where the doctors who scrutinize the bills and reports had already left since it was late evening. The following morning on Day 9 the claim was settled and the client was discharged.

This happens a lot and could happen to you too. So here are the steps you should take if you or a family member gets hospitalised:

  • The moment you get the go ahead for discharge, get behind the hospital staff to send papers/bills/documents and see that it happens as early in the day as possible so that claim settlement can happen on the same day and the patient is not held back another day simply as the claim could not be processed.
  • Keep the insurance policy in the loop especially in cashless claims. Check estimated costs as the treatment progresses and reviewit against the actuals.
  • Keep some cash handy as ‘Deductibles’ is the amount or small percentage of the total bill which you need to pay in most insurance policies.
  • Where your mediclaim is through re-imbursement, keep a copy of all the bills and cost of the treatment always.
  • Find out more about the treatment, why they are doing what – read up on it, ask around etc. The more knowledgeable you are and appear, lessor is the chance that you or your family member is kept behind in hospital longer than required.
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