Health Insurance Claim Procedures

Health insurance comes with additional benefits of cashless treatment and expense reimbursement by the insurer. One can file a claim against an event that is covered by the insurance policy taken. Following are two claim processes:

Expense Reimbursement:

Health insurance policies provide insured with the benefit of getting the medical expenses reimbursed by the insurer after paying them off, based on the policy terms documented. The cost of various hospital charges such as bed charges, medicines, lab tests, surgeon's fees etc. are paid back to the insured at the time of making a claim. The insured pays the (hospital) expenses incurred, but gets them reimbursed by the insurance company.

Cashless Treatment:

Insurance companies provide policyholders with a wide network of hospital get medical treatment without having to make upfront payments. No payment is required to be done by the insured but the insurer since the clause involves a mutual agreement between both the parties, i.e. the insurer and hospital. In contrast, availing cashless benefit requires TPA approval. The insured can also show the health card at the particular hospital as the proof of insurance cover along with a valid government ID proof. Following are the cases considered:

Planned Hospitalization:

In the case of planned hospitalization, the policyholder needs to have the TPA approval in advance along with the other mandatory documents to be submitted. Fill the pre-authorization form at the hospital with a particular section signed by the treating doctors.

Emergency Hospitalization:

Show the health card issued by the insurer at the hospital along with the pre-authorization form filled appropriately. Get the TPA approval for emergency hospitalization. If failed to get the TPA approval, get the expenses reimbursed later instead. The policyholder might have to show the itemized bill, proof of medical expenses, discharge bill etc for claim reimbursement as the proof of the treatment availed at the particular hospital.

Find the Best Medical Insurance Plans?

• Caps and sub-limits - Imposition of sub limits, co-payments or other caps might reduce the premium you pay for the insurance policy but in the long run it would alter the benefits. You should understand and assess this factor vis-à-vis your requirement and paying capacity to get maximum benefit out of a health insurance plan.
• Claim settlement record - This is an important criterion to assess the credentials of a insurance provider. You should always go with a company with has good claim settlement record. Thus you can ensure that your claims and reimbursements would not be wrongly withheld. Always ask for the company’s claim settlement ratio before purchasing their health plan and save yourself from unnecessary harassment.
• Scope of coverage - Just don’t buy a plan by comparing health insurance premium. Less amount of premium does not necessarily mean a good plan. On the contrary such a plan might not cover your needs properly. Closely look at what the plan covers. Buy a comprehensive plan. Scope of coverage essentially means the scope of protection provided under a contract of insurance, covering several risks covered by a policy.
• Renewability - It is important to see how many years the plan proposes to cover you. You should not be left without a proper cover when you need the most, say during your old age. Health insurance Mediclaim policies are usually annual contracts. The automatic re-establishment of in-force status effected by payment of premium is known as renewal. In other words, the issuance of a new policy or the continuation of a current policy that is effective once the old policy’s plan year ends is termed as renewal. At the end of the policy period, the policy has to be renewed by the policyholder. There should be continuous renewal of the policy, because if there is a break, then in the event of a contingency, the insured will lose the benefits of insurance.
• Cashless Hospital Network - Check if the hospitals around you are covered as a network hospital by the company you are considering to buy from. Cashless hospitalisation is hassle free and seamless. You and your family won’t be required to run around collecting documents and filling reimbursements. The insurer or its Third Party Administrator (TPA) have tie-ups with a network of hospitals and nursing homes called a “network hospital” across the country. The insured can get themselves admitted in these specified network hospitals and take treatment for the disease contracted without payment of cash. However cashless mediclaim settlement is subject to limits and sub-limits which are subject to the sum insured of the policy.
• Premium Loading - Loading is an additional cost built into the insurance policy to cover losses which are higher than anticipated for an insurance company, arising from insuring a person who is prone to a form of risk. Premium Loading is the amount an insurer needs to cover its expenses and generate profit. We would strongly recommend you to check the terms and conditions pertaining to premium loading. This will save you from paying a high incremental premium post making a claim. This aspect though ignored in the beginning usually becomes a bone of discontentment at a later stage. The best practice would be to verify the premium fluctuation data of the plan for previous 5 years at the very least.
• Internal Team - Check for the plans from insurers who have a dedicated internal team for handling Mediclaim. This comes in handy while expediting the Mediclaim claim settlement process. Most of the players use a third-party administrator (TPA) to process the claims and do the paperwork. Even though, most of these TPA provide great services, the fact that they are a third party slows down the process. There are certain rules and regulations to be followed when a TPA processes a claim before it is handed over to the insurance company. These affect the turnaround time.
• Floater (family) Size - Everyone has a different family size so you should always look for the family floater size allowed under the plan before buying it. In case, you are a person in your late 20s and your parents in their 40s, 50s or 60s already have a cover, then it makes sense if you buy an individual cover. Alternatively, if you are married with or without kids and have dependent parents, parents-in-law, siblings, etc. then a family floater is the best policy for you. Checking the premium, family size covered, critical illnesses or other treatment covered will ensure you are able to purchase the plan you need.
• Health Insurance Portability - It is best to choose a health insurance company that offers health insurance portability. Earlier, policyholders had to stick to a policy just to retain the waiting period benefit. Now, health insurance portability allows one to switch from one health insurance company to another without losing waiting period benefits earned in your existing policy. Moreover, with the policy landscape changing so regularly, life insurance companies regularly come up with better policies and it will make sense to opt for health insurance portability. Also, some companies may charge if you prefer to move away from their plans to some other players using the free health insurance portability option provide by the new company. Ensure you do not end up paying for health insurance portability instead of staying with the old insurer. Health insurance portability is a good thing to check when you are finding the best health insurance policy or mediclaim for yourself.

Benefits & Features of Health Insurance Policies

The cost of healthcare in the modern days is increasing at a high pace while one’s income does not seem to match up that level. Regular health check-ups are getting out of one’s range of affordability since multiple expenses of thousands are common in such scenarios. A patient looking forward to availing frequent health check-ups is no longer expected, whereas a health insurance policy easily covers all such expenses with assured benefits. A comprehensive health plan comes packed with features. Let us understand these features in detail so that buying a healthy policy becomes easy.

• Cashless treatment - Ev
• ery health insurance company or its Third Party Administrator has tie-ups with a network of hospitals and nursing homes called a ‘network hospital’ or ‘empanelled hospital’. If you get admitted in these hospitals, you don’t need to pay anything. Just tell your policy number and rest everything will be taken care by the hospital and the health insurance company. This type of plan is the most preferred because there is no stress of claim reimbursement and arranging documentation. However, expenses beyond limits or sub-limits allowed by the insurance policy or expenses not covered under the policy have to be settled by the insured directly with the hospital. Another important thing to remember is that cashless Mediclaim treatment or cashless facility is not available if one gets treatment in a hospital that is not part of the network.
• Pre and Post Hospitalization - This feature of health insurance policy takes care of both pre and post hospitalization charges for a period of 30 to 60 days depending on the plan purchased. It takes into account expenses incurred during a certain number of days prior to hospitalisation and post hospitalisation for a specified period from the date of discharge as part of the claim, provided the expenses are related to the disease/sickness.
• Ambulance charges - The policy holder is free from burden of transportation or ambulance charges as it is paid by the insurer. This is a add-on benefit and you should have opted for it while purchasing.
• No Claim Bonus - NCB or No Claim Bonus is a benefit provided if the insured does not claim for any treatment in the previous year. Benefit could be in any form, either an increment in the sum assured or a discount in premium. You can avail this benefit on renewal.
• Medical Check- Up - Health insurance policy entitles the policyholder to receive regular medical check-ups. Free check up is provided by few insurers provided you have a good history of no claim bonus.
• Tax Benefits - According to India’s tax system if you are paying a premium amount then you are liable to get tax rebate under section 80D of Income Tax Act for a maximum value of Rs.25000 for Indians in the age group of 18 to 50 years and Rs.30000 for senior citizens.
• Co-Payment - According to this feature you can lower the health insurance premium amount. Medical insurance plans offers co-payment option wherein there is a pre-defined amount of voluntary deductibles mentioned in the policy to be paid by the insured. So in case of a treatment, some amount is paid by the insured and rest by the insurer. It is a cost-sharing requirement under a health insurance policy that provides that the policyholder/insured will bear a specified percentage of the admissible costs. A co-payment does not reduce the sum insured.
• 
• Health Insurance Portability - Health insurance portability gives freedom to the policyholder to switch from one health insurance company to another without losing continuity benefits with respect to pre-existing diseases, waiting period and other time bound exclusions earned in the previous policies. Health insurance portability is subject to continuous insurance coverage in the previous years. Those covered under employer group health insurance or family floater policies can also make use of health insurance portability to port to an individual health cover. For this, they have to first switch to a plan offered by their existing health insurance company and after a year, they are allowed to switch to an insurer of their choice. Health insurance portability has come as a breather for policyholders who were trying to change their insurance company but were unable to do so earlier. With health insurance portability, they can now try out the policies they prefer with the insurance companies they prefer.

Health Insurance Policies in India

One needs to ensure the security of health of oneself and the family as well. With the increasing cost of healthcare and medical treatments across private hospitals in India, health insurance has become almost mandatory for everyone. Health insurance ensures not only health security but also hassle-free claim reimbursement. In today’s world of advancements, people have different choices even when it comes to buying health insurance. There are various plans readily available in India to cover every aspect of a medical emergency. Some popular types of policies are explained below:

Individual Health Insurance Policies:

This health insurance policy is designed to cover an individual against various illnesses with cashless hospitalization and other add-on features. The entire sum insured is available for only one individual and the premium is determined by the age of individual covered under the policy. It is a policy where each insured member is entitled to the entire amount separately.

Family Floater Health Insurance Policies:

With this health insurance policy, you can cover all your family members against diseases under a single cover. This cover offers a fixed sum insured for the family members that can be availed either by an individual member or as a sum total for treatment of one person. Family floater Mediclaim cover offers a fixed sum insured for the family members that can be availed either by an individual member or as a sum total for treatment of one person. Floater benefit means the sum insured as specified for the proposer under the policy, is available for any or all the members of his/her family for one or more claims during the tenure of the policy. As compared to individual plans, family floater Mediclaim plans come at a marginally incremental premium.

Surgery & Critical Illness Insurance Plans:

This is usually brought as a standalone policy or a rider in case of treatment against serious illnesses like- cancer, kidney failure, heart attack, paralysis etc. As the treatment of such diseases is expensive so the premium is also on a higher side. A critical illness is a serious, possibly terminal disease, strictly defined by the insurer. Most critical illness policies provide for payment of a lump sum benefit if the policyholder is diagnosed, suffering from one of a number of specified terminal conditions.

Pre-Existing Disease Cover:

After a waiting period of 2-4 years, various policies offer a cover against the pre-existing diseases -e.g. - diabetes, hypertension, kidney failure,

Senior Citizen Health Insurance Plans :

This health insurance plan is designed especially for senior citizens, offering protection from health issues during old age. According to IRDA, every insurer must provide cover for people up to the age of 65 years.

Preventive Healthcare:

Undoubtedly health care is expensive and who wants to fall sick; anyways. So, now we have preventive health care that offers to take care of you and not let your fall sick. This includes preventive care treatments like regular checkups, consultation charges and other tests or x-ray fees concessions. The idea is to monitor your health at timely intervals and provide overall health care benefits. Preventive Healthcare is medical care rendered not for a specific complaint but focused on prevention and early-detection of diseases. Some health insurance policies limit coverage for preventive care services, while others encourage such services.

Maternity Health Insurance: 

Health insurance companies today provide coverage against maternity and additional expenses, including both pre and post natal care, child delivery (normal or caesarean), which sometimes lead to vaccination of newborn babies. Maternity insurance covers the new-born baby up to the validity of the maternity insurance policy. 

Personal Accident Cover: 

These personal accident plans are frequently provided as riders to standard health insurance plans, which provide coverage for hospitalization and reimbursement of medical expenses, in the case of an accident. These are issued as fixed benefit policies, where specified sums are paid on occurrence of specified or unforeseen events such