A health insurance claim is when you request your insurer to compensate or provide for the medical costs for which you have been insured through the policy. Applying for a claim has been simplified a lot in recent times and here’s what you need to know about them.
What are the ways to make a claim?
There are two ways in which a claim is made:
a) Cashless – Cashless claims are possible when you are treated by one of the hospitals associated with the insurer’s network. For cashless claims, all you’ll need to do is provide the hospital with your relevant insurance details (your policy number and health card) and the bills will be sent to the insurer by the hospital. The hospital and the insurer will ensure that you are treated and cared for without spending a single rupee out of your pocket. But keep in mind that in case of a planned hospitalisation you need to inform the insurer 24 hours ‘before being admitted’ and for emergency hospitalisation, you have to do it ‘within 24 hours’ of being admitted.
In case your total bills exceed the coverage of your insurance policy, you will be asked to pay the remaining amount out of your pocket at the time of discharge.
b) Reimbursement – In case you get treated in a hospital outside of the insurer’s network then you would have to pay all the expenses yourself. You will then have to compile and send all the relevant documents (prescriptions, tests, medicine bills, etc.) to your insurer. The insurer will investigate the documents and will reimburse you the amount on acceptance of the claim. Keep in mind that there may be a 30-45 days waiting period to process and disburse the amount in this case.
What are the essential documents required for the claim?
The documents that you need to have in order for either kind of claim are as follows:
- Policy number and your health insurance card (if you have one).
- All the original bills, signed and stamped by the hospital.
- All the doctor’s report, diagnosis report, admission report, medicine bills, and any other bill covered under your policy.
- The discharge summary provided by the hospital.
Remember, you may need to send in the original papers for claims so it is advisable that you make copies of them and keep a copy for your personal records.
How to make a claim under multiple policies?
Many people buy more than one health policy to increase their overall cover. This is a good practice but you must remember that while purchasing a policy or claiming coverage, you must keep both the insurance companies informed that you have two policies. This disclosure is necessary to satisfy the ‘contribution clause.’
According to the contribution clause, an insurer will pay in proportion to the sum insured in the overall cover. Suppose you have ‘policy X’ with a cover of 1 lakh and ‘policy Y’ with a cover of 2 lakh, and a claim of Rs 50,000. Policy X will pay you Rs.16,666 and Policy Y will pay you Rs. 33,333 under the contribution clause.
The contribution clause, however, applies only if your claim is above the sum insured by one of the policies. Thus, according to the new rule, if we take the above example, the contribution clause will apply if your claim is over 1 Lakh. Suppose you claim Rs 1,50,000. This is above the 1 lakh cover of policy X. The contribution clause will kick in and policy X will pay you Rs. 50,000 and policy Y will pay you Rs. 1 Lakh, in proportion to the cover.
What happens with the defined benefit plans?
In a defined benefit insurance plan, like a critical illness plan, the policyholder is insured for pre-agreed specified illnesses. All you need to do is provide the documents (diagnosis, prescription, etc.) that are acceptable proofs for the insurer to inform that you have contracted the disease covered under the plan. The payments, in this case, are not linked to any of the expenditures incurred but to the contracting of the disease. You may receive the amount directly into your account or in ways mentioned in the terms and conditions of your policy.
Where do you file the claim?
- Network hospitals – If you are treated in one of the hospitals in the insurer’s network then you can simply visit the insurance desk at the hospital, provide relevant documents, and the staff will take care of the claims for you.
- Non-network hospitals – In case you are being treated at a non-network hospital, you can visit the insurer’s website to file the claim. Most insurers have a section on their website that will guide you through the process and you can complete the process easily online. Or you can check your policy guidelines to find the exact procedure for filing a claim.
- One Assure – One Assure also provides you with a one-stop option for filing claims and you can easily apply on our platform for claims redressal.
OneAssure is a distribution platform that helps you make right decisions on matters where health and finances converge. Visit oneassure.in to know more about your health insurance choices.