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| HOW TO MAKE A HASSLE FREE CLAIM |
1. Once the insured is admitted, he/she has to claim the following expenses:
a) Pre hospitalization period (30 days prior to the date of hospitalization)*.
b) Hospitalization.
c) Post hospitalization (60 days from the date of discharge)*.
2. The available options in the event one gets admitted are either cashless facility or claim settlement directly from the insurance company. These are both described below:
- Cashless Facility: Under this scheme, once TPA agrees to make payment directly to the hospital, the insured will not have to pay any money to the hospital except that is not permissible by the insured’s policy. Under the circumstances, the insured has a right to get reimbursement of his expenses on drugs, investigations and doctor’s fee for the pre and post hospitalization period by filing the claim papers with the TPA.
- Claim Settlement directly from the insurance company: If the insured has not opted for cash less facility, then he/she will have to pay hospital bill and would get reimbursed for the total expenses from the insurance company.
3. Information to TPA/Insurance Company has to be submitted within seven days of hospitalization.
4. Claim papers of the pre hospitalization period and/or hospital expenses have to be submitted with in 30 days from the date of discharge.
5. Claim papers of the post hospitalization period should be submitted within30 days of the permissible date.
6. TPA/Insurance Company is bound to settle the claim within 180 days of receiving the documents.
7. If you are diagnosed with an illness and are likely to make a claim. Inform your insurance company immediately. A simple letter giving details about the illness and your policy number is sufficient. Don’t forget to take an acknowledgement from the insurance company at the time of submitting the letter. If you are dispatching the latter by courier, remember to retain the proof of delivery.
8. If you are opting for cashless treatment always keep the number of the third-party administrator (TPA) and the insurer handy. Inform the TPA at least 48 hours before you get admitted to a hospital. In case of emergencies, inform the TPA within 24 hours of admission.
Normally, the TPAs are contacted by the hospital once one gets hospitalized. The relative of the insured should see to it and provide all details pertaining to illness correctly to avoid any rejection by TPA.
9. If you are spending for the treatment first and making the claim later on, or making claim for pre or post hospitalization period, be cognizant of the following:
- One has to submit all the papers in original.
- Ensure that the name of the patient and the doctor is mentioned on all investigation reports.
- Ensure the patient’s name is spelt the same way as it is spelt in the policy document.
- When the doctor prescribes medicines, ensure that the patient’s name is spelt correctly.
- While purchasing medicine, ensure that the chemist spells the name of the doctor and the patient correctly. If these are missing, your claim for those expenses may not be settled.
- Ensure the same while collecting the reports of various tests.
- At the time of discharge obtain a discharge card from the hospital
- While submitting the claim papers, make a proper file and cover letter, which clearly mentions the annexure being attached with the letter, and states clearly that all documents in original are being submitted. The papers may be submitted in the following order:
- The Original claim form and copy of the policy.
- Note from the doctor describing the illness and the recommended treatment.
- Original prescriptions from the doctor for medical tests (Investigation) and medicines. Original medical tests (Investigation) reports.
- Doctors and medical tests bills.
- Hospital and/or Nursing home bills.
- All the bills and their amount documented on a paper.
- Original Discharge card.
- Number all the pages in the file and obtain an acknowledgement before submitting the file.
- Always retain a photocopy of the complete set of the documents submitted to the insurance company.
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