Claiming health insurance- Know what you need to

In general, health insurance can be claimed only if the insured has been admitted into a hospital for a period of at least 24 consecutive hours. There are, however, some exceptions called ‘Day care treatments’ for which health insurance can be claimed even though the patient is admitted into a hospital for less than 24 hours.  These include eye surgery, chemotherapy, tonsillectomy, ligament repair procedure and prostate surgery amongst other procedures and will be listed in your policy document, if applicable.

What can you claim for

Health insurance usually covers not just the costs you incur during hospitalization, such as room charges, surgery and procedures, medical tests, etc., it also covers some pre and post hospitalisation expenses that are related to the condition for which you are hospitalised. All the heads that are covered under a specific policy are mentioned in the policy document that you receive when you purchase your insurance.

Naturally, you can only lodge a claim for conditions which are covered under your health insurance policy. So read your policy document carefully in advance to acquaint yourself with both the coverage and exclusions.

These days health insurance companies offer policies that cover a number of related expenses such as ambulance from the residence to the hospital and incidentals for the patient’s care-giver companion.  Some policies also cover domiciliary treatment, or treatment at home, under certain conditions. If such expenses can be claimed, it will be mentioned clearly in your policy document.

Claim processes

The process of claiming health insurance depends on whether you opt for the Cashless facility or Reimbursement of expenses, at the time of admission into the hospital. Cashless facility – There are a number of reputed hospitals that have tied up with insurance companies to offer patients a cashless experience, wherein the hospital bills are directly paid by the insurance company, to the extent specified in the policy. These hospitals are called ‘Network Hospitals’. In order to settle a cashless claim, you must avail treatment at a network hospital. At the time of admission (preferably before admission or within 24 hours after, in the case of emergencies) you must request the hospital administration to fill in the claims cashless request form and submit it to your insurance company/TPA. In reply, they will issue a letter to your hospital authorising financial limits on facilities and procedures, based on your policy coverage.  When you are discharged, the bills are settled directly by the TPA/insurer to the extent of your policy coverage and the authorisation of your insurance company.

Reimbursement of expenses – Here again, you must intimate your insurance company about your hospitalisation, preferably in advance but at least 24 hours after hospitalization, in case of emergencies. The claim management team of your insurance company will guide you on the process to be followed for reimbursement and related documentation. At the time of discharge, you have to pay the hospital bills and later submit them to your insurance company/TPA along with your prescriptions, diagnostic reports, discharge summary and other specified documents.

Claim rejection

One of the biggest fears of health insurance policyholders is that after paying the premium and expecting to benefit from the policy, they will be let down by a rejection after lodging a claim. And this does happen sometimes for various reasons such as non-disclosure of material facts about the condition of health at the time of purchasing the policy, lack of clarity on the part of the policyholder with regard to the terms of the policy and misunderstandings on the process to be followed, etc.

Simple steps such as reading and understanding the policy carefully, clarifying any doubts with the insurance advisor or company’s customer care executives, being honest and upfront about existing health conditions and issues at the time of purchasing the policy, following the claim procedure carefully etc., can pre-empt any claim rejection.

Claim a stress free recovery

Once you have purchased a health insurance policy that adequately covers your needs, you can rest assured that in the case of an illness that is covered, your finances will be taken care of. Don’t let oversights and unawareness deny you of this right. So do your homework in advance and when you or a loved one is unwell, make sure that your complete focus is on nurturing yourself or your loved one back to health!

(The author is MD & CEO, Religare Health Insurance Company Ltd)