Beeinsured Blog

Health Insurance Claim Process
Health Insurance

A Claim process of health insurance is very specific and depends on the insurance company you choose. Generally, below are the expenses which are covered under a Health Insurance Policy:

  1. Hospital (Room & Boarding and Operation Theatre) Charges
  2. Fees of Surgeon, Anesthetist, Nurse, Specialist, etc.
  3. Cost of Diagnostic Test, Medicines, Blood, Oxygen, internal appliances like pacemaker, etc.

Health Insurance claim can be taken in two ways:

  1. Cashless Claims
  2. Re-imbursement Claims

A Cashless Claim can be only made when the insured gets his treatment at the Network Hospital across the country. Every Insurance company has a List of cashless hospitals where they can undergo a treatment. Let us look at the General Claim Process followed by Insurance Company at Network Hospital.

CLAIM PROCESS IN CASE OF CASHLESS TREATMENT AT NETWORK HOSPITAL

Step 1: Claim Intimation

  • If your hospitalization is planned, kindly intimate the Insurance Company 48hrs prior to admission.
  • If your hospitalization is an emergency, please inform the insurance company within 24hrs of your admission.

While registering a loss or claim, below given details are required

  • Policy Number
  • Contact Details of the Claimant/ Policyholder’s (Phone No., Address, Landmark, etc.)
  • Name of the Insured/ Claimant person, who is hospitalized
  • Hospital Details
  • Nature of Ailment (For Health Claims)
    • Commencement date of the symptoms of ailment
  • Accident (For Accidental Claims)
    • Nature of Accident
    • Date & Time of Accident
    • Location of Accident

Step 2: Initiating the Pre-Authorization Process

  • A Pre-Authorization will be available at the Hospital’s Insurance/ TPA Desk. You may also download the form from the insurance company’s website.
  • The Insured/ Family member needs to fill in the First Section of Pre-Autho Form (Personal Details with Signature) and hand over to Hospital’s Insurance/ TPA Desk for filling up the balance details.

Step 3: Submitting the Pre-Authorization Form

  • Hospital will verify the details & add the required information and fax the Completed Pre-Authorization form to the Insurance Company.

Documents required for Cashless Approval

  • Pre-Authorization form at the Hospital
  • Health Insurance TPA Card
  • ID Proof of the Insured & the Policy Holder
  • Past Medical History Papers (If any)/ First Consultation Letter/ Investigation Reports
  • Any relevant documents as required

Step 4: Processing the request for Pre-Authorization

  • Our in-house medical team will review the case and documents submitted by hospital
  • Claim Status shall be sent across to the Hospital.

Health Insurance Cashless Claim

Step 5: Photocopy of Bills

  • Retain a Photocopy of your Hospital bills for maintaining your medical records.

We have also listed down the major reasons for Claim Denial or Query Raised by the Insurance Company.

REASONS FOR DENIAL OF CLAIM/ QUERY RAISED BY THE INSURANCE COMPANY:

TOP REASONS – DENIAL OF CLAIM

TOP REASONS – QUERY RAISED

·        Treatment in Non-Network Hospital

·        Further Scrutiny of Claim

·        Hospitalization for Illness/ Diseases which are not covered

·        Not Disclosing all medical details

·        Waiting Period, Co-pay and Deductibles

·        Lack of Pre-Authorization or Pre-Certification from the specialist.

·        Missing/ Incomplete Information on the Pre-Authorization Form

·        Incomplete Details about the Test, or No reports attached

·        Claim Submitted for Non-Payable Expenses

·        Insufficient Medical necessities.

·        Bills Tampered, Name Misspelled, Incorrect Patient Details

 


O
ur Role:

While registering a Claim, it is important to check whether the hospital is in the Network panel and follow the above steps for faster processing of your claims. We have a dedicated Claim’s Team to handle your queries and help you resolve your queries.

HOW BEEINSURED HELPS YOU DURING YOUR CASHLESS CLAIMS

If you would like to know more about the services we provide or need any assistance with your claim, please click on the link below.

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