Claims Settlement Process
Health Insurance Claims Settlement Process:
In most cases, the Insurance companies appoint a Third Party Administrator (TPA) for claims processing. That means once the health insurance policy is sold, the insurer passes on the complete details to the TPA. In case of a claim, the insured has to get in touch with the TPA for all verification and formalities.
Two Ways By Which Health Insurance Claims Are Settled:
- Cashless:
For planned hospitalization at authorized network hospitals, the TPA has to be notified in advance for availing cashless treatment or within the stipulated time limits for emergencies. The insurance desk at hospitals will generally help with all the paper work. The TPA has to approve the claim amount and the hospital settles the amount with the TPA / Insurer. There will be exclusions which will have to be settled directly at the hospital by the insured.
- Reimbursement:
Reimbursement facility can be availed at both the network and non-network hospitals. The hospital bills are directly settled at the hospital after the insured avails the treatment. The insured can then claim reimbursement for hospitalization by submitting relevant bills / documents for the claimed amount to the TPA.
The TPA mode of claims settling has its own problems. The TPA is incentivized to limit insurance claims and they are not the ones who sell the policy. There are many cases where the insured had a tough time to claim for his hospital expenses. So before taking a health insurance policy, check who the TPA is and how good they are when it comes to claims processing. Internet search and a friendly chat with the hospital staff can give you good insight on the insurer / TPA. There are also some health insurance providers who do not employ TPAs and manage claims settlement directly which is called In-House TPA.
