Medical claim
A medical claim refers to a request for payment or reimbursement for healthcare services submitted by the insured to their health insurance provider. The claim is made when an individual covered under a health insurance policy incurs medical expenses due to illness, injury, or hospitalization. The insurance company evaluates the claim and provides payment for the medical services as per the terms and conditions of the insurance policy.
Medical claims can be filed for a wide range of healthcare services, including doctor visits, surgeries, diagnostic tests, medications, and hospital stays. There are two primary types of medical claims: cashless claims and reimbursement claims.
Types of Medical Claims:
Cashless Claims:In a cashless claim, the insurance company directly settles the medical bills with the hospital or healthcare provider, meaning the policyholder does not have to pay upfront for the covered services. This facility is available only at hospitals that are part of the insurer's network hospitals.
To avail of cashless treatment, the policyholder must inform the insurer in advance for planned treatments or immediately in the case of emergencies. Upon approval, the insurance company directly pays the hospital for the covered expenses, except for any deductibles, co-payments, or non-covered expenses.
Reimbursement Claims:In a reimbursement claim, the policyholder pays for the medical treatment upfront and later submits a claim to the insurance company to get reimbursed for the expenses. The insured must provide all relevant documents, such as hospital bills, medical reports, and discharge summaries, along with the claim form.
The insurance company reviews the claim, and if the expenses are covered under the policy, the insured is reimbursed for the approved amount. Any non-covered expenses or amounts exceeding policy limits are borne by the insured.
Steps for Filing a Medical Claim:
For Cashless Claims:
Choose a Network Hospital:The policyholder must seek treatment at a hospital that is part of the insurer’s network hospitals to avail of the cashless facility.
Pre-authorization Request:For planned treatments, the policyholder must submit a pre-authorization form to the insurance provider before admission. In the case of emergency hospitalization, the hospital can submit the form on behalf of the patient at the time of admission.
The pre-authorization form includes details about the patient, the nature of the treatment, estimated costs, and the policy number.
Approval of Cashless Claim:The insurance company reviews the pre-authorization request and, if approved, directly communicates with the hospital, authorizing the cashless treatment. The insurer will cover the medical expenses as per the policy terms.
Pay Non-Covered Expenses:The policyholder is required to pay for any non-covered expenses, deductibles, or co-payments as specified in the insurance policy. These may include charges for certain services, consumables, or items excluded under the policy.
Settlement of Bills:After treatment, the hospital submits the final bill to the insurer for settlement. The insurance company will pay the approved amount directly to the hospital, and the policyholder will only need to pay for any remaining costs not covered by the insurance.
For Reimbursement Claims:
Pay Medical Bills:In the case of a reimbursement claim, the policyholder must initially pay all medical expenses out of pocket.
Collect Necessary Documents:
After the treatment, the policyholder must collect all the necessary documents for filing a claim, including:Original hospital bills and receipts.
Doctor’s prescriptions and diagnostic test reports.
Hospital discharge summary or treatment summary.
Claim form (filled and signed).
Any other supporting medical documents required by the insurer.
Submit Claim to Insurer:The policyholder submits the filled claim form along with all supporting documents to the insurance company, either online or through mail, depending on the insurer’s claim process.
Claim Assessment:The insurance company reviews the claim, verifies the documents, and evaluates whether the expenses fall under the coverage of the insurance policy.
Reimbursement:If the claim is approved, the insurance company reimburses the policyholder for the approved medical expenses, subject to the policy limits and terms. The insured will receive the reimbursement via direct bank transfer or check.
Documents Required for Medical Claims:
Duly filled and signed claim form.
Original hospital bills, receipts, and payment vouchers.
Hospital discharge summary or treatment summary.
Doctor’s prescriptions and diagnostic test reports.
Pharmacy bills for medications.
Investigation and diagnostic test reports (X-ray, MRI, blood tests, etc.).
Any pre-authorization approval letter (for cashless claims).
Identity proof (Aadhaar card, PAN card, etc.).
Health insurance policy document and policy number.
Cancelled check or bank details (for reimbursement claims).
Key Terms in Medical Insurance Claims:
Sum Insured:The maximum amount the insurance company will pay for medical expenses in a policy year. If the medical bills exceed this amount, the policyholder must pay the difference.
Co-Payment:A percentage of the medical expenses that the policyholder is required to pay out of pocket. For example, if the policy has a 10% co-payment clause, the insurer will pay 90% of the claim, and the policyholder will bear 10%.
Deductible:A specified amount that the policyholder must pay before the insurance company starts covering the medical expenses. For instance, if the deductible is ₹10,000, the policyholder must pay this amount, and any expenses beyond this will be covered by the insurer.
Pre-existing Conditions:Medical conditions that the policyholder had before purchasing the insurance policy. Most insurers impose a waiting period (typically 2-4 years) before they cover expenses related to pre-existing conditions.
Waiting Period:The time period during which certain medical conditions or treatments are not covered by the insurance policy. For example, maternity benefits may have a waiting period of 1-2 years.
Exclusions:Specific medical conditions, treatments, or expenses that are not covered by the insurance policy. Exclusions can vary by policy and may include cosmetic surgeries, dental treatments, or injuries from self-harm.
Common Reasons for Medical Claim Rejection:
Incomplete or Incorrect Documentation:If the submitted documents are incomplete, missing, or filled with incorrect information, the claim may be rejected.
Treatment Not Covered:Claims may be denied if the treatment or medical condition is not covered under the policy or falls under the exclusions.
Exceeding Policy Limits:Claims that exceed the sum insured or sub-limits for specific treatments may be rejected or partially approved.
Pre-existing Conditions:Claims related to pre-existing conditions may be rejected if the waiting period for such conditions has not been completed.
Delayed Submission:Claims may be rejected if they are not submitted within the specified timeframe, typically 30 to 60 days from the date of treatment.
Non-disclosure of Information:Failure to disclose relevant medical history or pre-existing conditions at the time of purchasing the policy can lead to claim denial.
Tips for Smooth Claim Processing:
Know Your Policy:Read and understand the terms, conditions, inclusions, and exclusions of your health insurance policy. This ensures you are aware of what is covered and what is not, avoiding surprises during the claim process.
Keep Documents Organized:Maintain all original medical bills, receipts, and reports in an organized manner. Submit the required documents in full when filing a claim to avoid delays or rejection.
Inform the Insurer Early:In the case of planned treatments, inform the insurance company well in advance and obtain pre-authorization for cashless claims. In emergencies, notify the insurer or hospital as soon as possible.
Submit Claims on Time:Ensure that claims are submitted within the specified timeframe mentioned in the policy. Delayed submission can lead to claim rejection.
Clarify Any Doubts:If you are unsure about any aspect of the claim process, contact your insurance provider for clarification to avoid mistakes during the submission.
Conclusion:
Medical claims are an essential part of health insurance, providing financial protection against medical expenses. Understanding the types of claims, the documents required, and the claim process can help policyholders ensure that their claims are processed smoothly. Whether opting for a cashless claim or filing for reimbursement, it’s crucial to be well-informed about your insurance policy and adhere to the necessary procedures to avoid delays or rejections.