Knowledge Centre

Dos and Don’ts of health claims

Life-style diseases, stress, increasing medical cost - healthcare has become an expensive proposition; especially when medical intervention becomes necessary.  Health insurance is no longer merely an employee incentive or tax-saving measure, it has become a need. Hence, Insurance companies have gradually expanded into specialised products such as critical illness insurance plans for life-threatening ailments. But the extended claim settlement process often discourages many consumers from buying health insurance.

Health insurance claim settlements need not be a stressful and frustrating experiencehowever. A little planning andadherence to a few dos and don’ts can make the entire process simpler and faster.

 

Dos:

While purchasing the policy:

  • Provide complete and correct information
  • Ask about exclusions, limits, sub-limits, etc
  • Read the Policy wording
  • Disclose pre-existing medical conditions

    While filing claims:

    Claims can be made under cashless arrangement or by way of reimbursement. The insurance company/ third party administrator (TPA) must be informed if it’s cashless, and only the insurance company needs to be informed if it’s via reimbursement.

  • In emergency cases, Insurance Company should be intimated within 24 hours of hospitalization
  • If the procedure is planned in advance, complete the relevant paperwork/ formalities 3-4 days in advance
  • Most insurers insist on a 48 hours advance intimation to complete the pre-authorization process. Keep your health card ready and handy. Remember that the cashless facility works only in network hospitals (hospitals that are on the insurers pre-approved list)
  • Ensure the pre-authorization form/ cashless request form is complete and correct and signed by the attending doctor
  • Provide OPD consultation papers for planned hospitalization
  • Furnish all bills, prescriptions, consultation receipts, medical reports, letter from doctor advising hospitalization, stamped hospital bills and receipts etc.
  • Settle all expenses if the process is not cashless and get the receipts. Do note that even for a cashless claim, there might be some expenses that will need to be borne by you. You need to settle those
  • If treatment is availed at a non-network hospital, customer has to pay for the whole treatment. After discharge, he can submit all the documentation and required report to the insurer. The insurer will check all the documents and approve whatever it finds reasonable.
  • Ensure complete and correct information in claim settlement forms. The form should be submitted within the time frame stipulated in the policy. All original hospital bills/ receipts should be duly stamped and signed by the hospital.

General:

  • Ensure timely payment of premiums so that the policy does not lapse
  • Give fresh bank mandate for reimbursement, if necessary
  • Maintain a complete medical record, including copies related to old insurance, prior claims made, if any
  • Keep insurer updated of relevant developments in your life

 

Don’ts:

  • Don’t hide any information related to your health condition as it can hamper your claim settlement
  • Don’t opt for facilities or rooms that exceed your approved upper limit
  • Don’t delay reporting and submitting relevant documents to the insurance company/ third party administrator
  • Don’t forget to seek extension of time to submit evidence, if required
  • Don’t forget to renew your policy on time
  • Don’t make false or questionable claims

With a little foresight and planning, making a health insurance claim can be simple and effortless. More so, when you opt for a health insurance company like HDFC ERGO, who has partnered with a wide network of hospitals and also has a dedicated claim settlement team in place, guiding and assisting you, ensuring a hassle-free, quick claim settlement.

Disclaimer - The above information is for illustrative purpose only. For more details, please refer to policy wordings and prospectus before concluding the sales.


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