Health Insurance Policyholder's Responsibility During Claim Settlement

If you have any type of insurance (Family Floater, Maternity Insurance, Personal Accident Insurance etc.), then you must have taken it to secure yourself or your family members in case of an unfortunate incident. Health insurance provides financial and mental security in medical emergencies by providing you with the option to claim the medical expenses incurred from the insurance company. When you receive money from the insurance company, it is called ‘claim settlement’ and to inform your insurance company about any untoward/medical condition/emergency is called ‘claiming’.

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If you are going to take a policy from a health insurance company, then as a conscious customer, you must find out about the claim ratio. A lower ratio means that the insurance company has made fewer claim settlements, whereas a higher ratio means the company has made more settlements. A high claim ratio is preferable as it indicates that there is not a lot of confusion in the terms and conditions of the policy.

For example, suppose a health insurance company has received 1000 claims and that company has settled 950 claims, then the claim settlement ratio of the company will be 95%, while the claim cancellation ratio will be 5%. Care Insurance under myUpchar Bima Plus has a claim ratio of more than 95% and ranks second in this case.

Wondering who issues this claim ratio? Well, every year the insurance regulator releases data related to the claim settlement ratio so that as a customer, you can decide which insurance company suits you best.

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Another factor to keep in mind when buying a policy is the cashless facility as it is the only facility under which you do not have to pay any amount to the hospital. If your insurance offers this facility, only a few simple formalities have to be completed, after which the insurance company will settle the claim with that hospital. Since it may be difficult for many people to arrange money at short notice in the case of an emergency, it is very important to have this facility. Note that you can avail of this facility only at hospitals included in the insurance company’s network. Hence, it is the responsibility of the customer to ask about cashless facility while choosing a policy.

(Read more: What is cashless health insurance)

Following are a few things to keep the following things in mind while buying an insurance policy:

Don't hide your medical history: Candidates buying insurance should be careful not to hide their medical history (information related to past diseases and their treatment) while taking insurance. People often make this mistake and blame the insurance company and agent when their claim is not processed in their time of need. We advise you to tell the truth about your medical history to the insurance company while buying a health insurance policy. In some cases, the company may issue the policy to you by charging an extra premium. It may also happen that the company refuses to give you the policy or to cover a particular disease.

Fill the proposal form correctly: While filling up the proposal form, it is the responsibility of a policyholder to:

• Fill the form yourself
• Don't fill the form in haste
• Read and understand all the points
• Do not give incomplete or incorrect information in it
• Do not leave any of the columns blank
• Do not sign a blank proposal form, as you will be responsible for any information contained in this document
• Select the term of the policy as per the requirements
• Choose a premium amount that can be easily paid by you
• Choose the premium payment frequency such as yearly, half-yearly, quarterly or monthly
• Choose the payment option that suits you
• Select the nominee under your policy. Fill in the name of the nominee correctly.

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After buying a policy, keep the following things in mind:

• Cross-check the policy: Once the proposal is accepted by the insurance company, the policy bond should reach you within a reasonable time, failing which it is your responsibility to approach the insurance company regarding the same.
  • When the policy bond is found, check it and make sure that the policy is exactly what you wanted.
  • If you have any doubts about the policy bond, immediately contact the intermediary/insurance company official for clarification.
  • Contact the insurance company directly if necessary.
• Know about network hospitals: After taking the policy, it is the responsibility of a policyholder to first check the list of network hospitals. Find out which hospital in your vicinity is listed with the insurance company so that, in case of emergency, you can go to the same hospital if possible. Apart from this, keep in mind that the hospital you want to go to should offer the treatment you’re looking for as well. Under myUpchar Bima Plus, you get a cashless claim facility in more than 8,300 network hospitals.
• Be careful about the exclusion list: Exclusions are cases for which the insurance company does not provide coverage. Therefore, it is the responsibility of the customers to check the exclusion list so that they are aware of the type of disease, condition or treatment they cannot make a claim for.
• Keep documents handy: In important matters like making a insurance claim, you need to be careful with the documents. It is the responsibility of the insurer to keep all the documents related to the insurance safe, as the claim can be rejected if all the paperwork is not in place. Typically, these documents include bills related to surgery and medicines, hospitalization and discharge papers, preauthorization forms and policy cards. As there is usually a separate box for medicines at home, you can also keep emergency documents in one place from the very beginning and tell at least one other family member about it.
• It is important to claim on time: There is a difference between making a claim and making a timely claim. The policy bond contains information about when you should make a claim. Generally, when you plan for network hospitalization, inform your TPA two days in advance, whereas in case of sudden admission you need to inform the TPA within 24 hours. In case you don’t file the claim on time, there is a risk of cancellation of the claim.
• Don't forget to renew the policy: As a responsible insurance policyholder, you must know the timing of policy renewal. Usually, this time is for one year, after which you need to renew. Let us tell you that almost all the insurance companies provide the facility to renew the policy through both online and offline modes. If you have not renewed in time and there is a need to make a claim during that time, then the claim can be rejected.

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If you have taken health insurance and have to make a claim, then you should also know about the claim settlement. Since we rely on health insurance in times of trouble to get financial help, we should know in how many ways the claim settlement is done:

Cashless claim: With this facility, one is not required to make any cash or other payment at the hospital. If a person who has taken health insurance with a cashless facility needs to be admitted to a network hospital due to any medical condition or illness, they can make a cashless claim. 

In case you plan to go for treatment at a network hospital, you should inform your TPA, keeping in mind the timings mentioned in the policy bond. Whereas if you need emergency treatment, you should inform the TPA within 24 hours of your admission. For the claim, you need to go to the insurance desk at the hospital and ask for the preauthorization form, fill it with the correct information and then submit it. You’ll be asked to show the policy card. If you want, you can download this form from the website of the insurance company, take a printout of it and fill it as well. After this, the hospital will send your application to the insurance company through fax, where the form sent by you will be checked. If the form is filled correctly, the insurance company will fax the hospital to inform them that they have approved the claim. The insured will not have to pay money anything during this entire process. If your claim exceeds the sum-insured amount, you may have to pay that extra amount.

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Reimbursement: In this claim method, the entire hospital bill has to be paid by the patient or his family at first. After the treatment, the discharge papers of the hospital as well as all the papers related to the treatment have to be submitted to the TPA office. The TPA sends all the documents to the insurance company, where they are verified. After checking the paper, the insurance company contacts the hospital and if everything is as per the terms and conditions, then you get the entire hospital bill or, in some cases, some percentage of the bill returned to the insured. Keep in mind, in the case of reimbursement, the money is not available immediately but after a few days. Whereas in cases of post-hospitalization expenses, the insurance money is transferred to the account a few days after the completion of the treatment. Insurance money is usually transferred after 30 days but it depends on the company.

Checking the status after making a claim is also the responsibility of the policyholder or their nominee. To check the status of your health insurance claim online, you need to follow the steps mentioned below:

• Visit the official website of the insurance company.
• Visit the claim page.
• Enter the required details like policy number, customer ID, claim number, etc. and submit.
• You will know the status.

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For making an offline claim, the insured or the nominee needs to visit the insurance company's office (nearby branch). In health insurance companies that have TPA (Third Party Administrator), you can also claim by going to the TPA instead of going to the office, but in those who do not have TPA, the claim is made directly from the office of the insurance company and this service Makes claim settlement much faster, as here you directly submit the documents and here the claim is settled after verifying them. However, this entire process may take a few days, for which one can visit the office as well as talk to the customer care to know the status.

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The following documents are generally required for making health insurance claims:

• Original investigation report
• Pharmacy bill along with prescription (given by the doctor)
• FIR or post-mortem report (if required)
• Hospital bills, receipts and discharge reports
• Valid photo ID proof
• Photocopy of policy or health card
• Treating doctor's report
• Discharge summary
• Filled claim form
• Test report, written by a doctor or surgeon

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