Mediclaim policy: How to claim reimbursements?

Earlier, in an interview to CNBC-TV18, Harshvardhan Roongta, Roongta Securities had explained about cashless mediclaim policies. In the current interview, he threw light on how one can get reimbursement from their mediclaim policy.

Also read : What to look out for in mediclaim policies?

"Some important factors to remember while reimbursement is the claimer must read the notice of claim; he must intimate the insurance company of the hospitalisation. Also, keep the original discharge card, the final bill, the receipts of the payments etc all these need to be in place," he explained.

He further clarified, "The mediclaim policy prescribes and assures to bear all the claims which are related 30-days prior to hospitalization and 60-days post hospitalisation."

Below is the edited script of his interview with CNBC-TV18's Latha Ventakesh and Reema Tendulkar

Q: Last time we spoke about how to go about cashless transaction for mediclaims policies. How do you go about claiming reimbursements for the same?

A: I would suggest that the moment the person gets his policy documents, the first thing he should note and read is the notice of claim section. This section prescribes the time limit within which the documents need to be submitted. So before we get on to which documents we need to submit, a policyholder needs to know when and by what time the documents need to be submitted.

One of the most important factors that most of the policyholders neglect to do is intimation of hospitalisation. In the cases of reimbursements, the insurance company needs to be informed that a hospitalisation has taken place or is likely to take place. There is a special section which mentions and specifies the time period within which the insurance company needs to be intimated about the hospitalisation. Either you could do that by making a call or writing to the insurance company or emailing it to them. This first step is very important.

Common question asked by people is what is the need for intimation to the insurance company, when documents are going to be submitted later on? The insurance companies want to know that there is hospitalization that has taken place. At the same time, they may want to appoint a surveyor who would physically come into the hospital to visit you, to have a look, to verify the authenticity of the claim and to also check the line of treatment the hospital is giving because it directly affects the claim.

Now with regards to what documents need to be in place, you need to first make sure that all the original bills are in place. All the receipts for the payments that you are making, all the prescriptions, if you are buying a medicine or something from outside chemist, it has to be prescribed for. You cannot simply go and buy something that you feel like should be administered upon you. All these original documents need to be in place at the time of discharge. You need to make sure that original discharge card, the final bill, the receipts of the payments all these are in one place, so that they can be submitted to the insurance company.

Q: What about pre-hospitalization expenses? Even for diagnoses and possible blood tests and other kind of tests you go through well before hospitalization, will they also be reimbursed and what about post-hospitalization expenses?

A: The mediclaim policy prescribes and assures to bear all the claims which are related 30-days prior to hospitalization and 60-days post hospitalization. If there is any expense that a person has incurred relating to the hospitalization, it cannot be something else unrelated to what you have been hospitalized for. So expenses incurred 30-days prior to the hospitalization and 60-days post hospitalization will be covered by the mediclaim policy.

The process for claiming that is the same. You need to fill in the same claim form. You need to have all the original bills which need to be submitted to the insurance company and within the time period. That is important.

Caller Q: My employer had given me a family floater medical insurance coverage from New Insurance Company. It covers me, my wife and my father who is of 65 years of age. This policy is active since 2003. Now my employer wants to shift to another insurance company which is unwilling to cover my father. What should I do? Is New Insurance Company bound to carry forward previous coverage?

A: If your employer has chosen to switch to another insurance company, the terms and conditions of that group insurance mediclaim policy is negotiated afresh with the new company. So there is very little that you can do in this perspective.

Secondly, you cannot force the new insurance company to accept the proposal as the National Insurance Company has offered it to you because the insurance companies have to bear the claim themselves. It is absolutely at that discretion where they should accept and at what terms they want to accept the insurance.

The question is what options do you have? You can port this group medical policy into an individual family floater policy. So that portability is mandated and National Insurance Company cannot deny you that benefit. So the first step that you should be doing is the group family floater policy that you have offered by your employer port it to an individual family floater policy with National Insurance Company itself. Continue with it as an individual policy but you will have to pay the premiums for the same. After one year is completed, you take a call whether you then want to port it to another insurance company which is accepting it or you simply continue your coverage with National Insurance Company.