In a day-to-day life so many times we find
people who are complaining about insurance companies. All the hassles and paper-work
to be done and yet at times the claims are unsettled for various reasons. Many of
us buy health policies in March to get tax advantage and many buy it to oblige their
friends and relatives who are ‘agents’. There is very little
awareness about the advantages of health insurance Very few realize the importance
of a health insurance policy
and have the knowledge of how a health policy can work to one’s advantage.
Knowing and understanding the product is only half-cooked food. It is also apparent
to know the claim and settlement process. It is required to understand the role
of the TPAs, documents that may be needed, policy documents, cashless card etc.
For better understanding of the processes, few quick tips are mentioned
A) Hospitalization in Network Hospitals
company has a list of paneled hospitals across India. Cashless hospitalization can
be availed at any of the hospitals in the panel. For Availing the Cashless facility
at these hospitals, one has to go through the TPA (Third Party Administrator). It
is the TPA that will authorize “Cashless Service” at the empaneled
hospitals in all cases eligible under the insurance policy.
As soon as possible inform your TPA (The contact number
for the TPA will be mentioned in the policy or available on the respective insurer's
website) and coordinate with the hospital to have the details sent to TPA
for authorization of cashless service.
On discharge, verify and sign the bills and pay for the items that are not payable
under the health policy (Policy document contains all the details about the expenses
covered & not covered)
discharge summary and other investigation reports should be handed over to the hospital. Please
retain a photocopy for your records.
In case of a planned hospitalization, kindly coordinate with the hospital and send
in all the details of your hospitalization at least 3 days prior to the admission,
including the plan of treatment, cost estimates etc. to TPA. Also indicate the contact
details of the hospital to send the authorization.
B) Hospitalization in Non - Network Hospitals
as possible, inform TPA about the hospitalization. At the time of discharge, settle
the hospital bills in full and collect all the bills, documents and reports. Register
your claim with TPA for processing and reimbursement.
lodge your claim with TPA for processing and reimbursement?
Please register your claim with TPA within 7 days of discharge. Kindly send the
documents listed below for processing your claim:
Duly signed claim form
Copy of Policy Document
All hospital bills in original with
detailed breakup for consolidated amounts
Bills for medicines purchased from outside, should be accompanied with a doctor’s
Discharge summary / Discharge
card in original
All investigation reports
Documents in addition to
those mentioned above may be called for depending on the nature of claim lodged.
Please retain a copy of the documents sent for your records.
Most importantly, the delay in intimation of claim may lead to rejection of claim.
If above is taken care then one can be assured that he will not have to
face much hassles during his/her claim settlement.