The Procedure of Filing a Health Insurance Claim

If you are covered underhealth insurance plans then there are two methods to place a claim namely

  • Cashless Hospitalization
  • Non-cashless hospitalization

Cashless or Planned Hospitalization

  • Under the planned hospitalization program, you need to inform the health insurance company or the Third-Party Administrator of the patient’s admission date in the hospital along with your Health Id card and policy number at least 4 to 5 days in advance.
  • You can get the pre-authorization for cashless claims services and the intimation form to be sent to the third-party administrator from the admission counter of the hospitals
  • You must fill up the form with due care as incorrect information may lead to rejection of previous authorization. 
  • The doctor attending the patient must fill in the medical condition of the patient or requirement of any surgical procedure. Make sure to brief the doctor correctly about the medical history of the patient else, a risk rejection of pre-authorization from the insurance provider exists.
  • Subsequently, the hospital authorities send the filled-up form to the respective insurance company for granting the amount of pre-authorization involved in hospitalization.
  • Next, the insurance provider scrutinizes relevant details like policy number, waiting period, sum assured, pre-existing diseases, etc. If satisfied they will send the authorization amount directly to the hospital.
  • The insurance company will issue a pre-authorization letter or guarantee of payment to the nursing home or hospital stating that the sum guaranteed as payable concerning the ailment for which the person seeks admission as a patient.
  • Third party administrator may deny the pre-authorization if it is not satisfied with the documentation
  • It becomes essential to relentlessly pursue authorization letter because unless provided the hospital; will not treat it as a cashless claim.
  • In case the Third-Party Administrator does not issue the letter,the patient has to pay from his pocket and then lodge a claim for reimbursement.
  • In case of planned hospitalization, it is easy to get pre-authorization as the policyholder has ample time to follow up the service provider. However, things get tough in case of emergency hospitalization.  Time is significant, as the hospital will not start treatment if it does not receive authorization or cash from the insured.
  • Third Party Administrators grant authorization for only the amount agreed on the policy. If the cost of treatment exceeds the agreed amount, the patient must pay the excess fee and then place a claim for reimbursement if permitted in the policy. 

 Non-cashless Hospitalization/ Emergency Hospitalization

The patient must submit an initial intimation within seven days of hospitalization to the third-party administrator or health Insurance Company. The notice must provide:

  • Particulars of policy number
  • Health Id card number and copy
  • Name of the Insured Person
  • Address
  • Attending doctor’s name
  • Hospital name
  • Nature of injury or illness  

Within 30 days from the date of discharge, you must submit the final claim. The intimation period may vary between insurance companies. If you want some more health insurance plans then visit www.cover360.in/health-insurance now.

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