Key Procedures for Filing a Healthcare Insurance Claims

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In certain circumstances health insurance claims can be a frustrating process and more so if there is no help from the healthcare provider. Often People are left to fend for themselves while filing a health claim for a medical reimbursement procedure which occurs after hospitalization. In such a situation cashless facility will not provided by the hospital or nursing home.

The expenses incurred on hospitalization can be claimed only after the patient gets discharged from the hospital or on completion of treatment.

If an individual has to file his own insurance claim, the following points should be borne in mind:-

a) Keep all receipts and arrange them in chronological order

b) Get the claim form from the insurance company

c) Prepare copies of the original for the purpose of claim submission

d) Review and dispatch documents

e) Understand the fine print in the policy document

a) Keeping all receipts in Order

• You are advised to keep not only all receipts, bills and medical reports as part of the hospitalization but also the ones obtained during 30 days prior to hospitalization and 60 days (only relevant bills) subsequent to hospitalization. The medical services availed during this period as part of the same treatment, are generally applicable to be reimbursed.
• These medical bills, receipts etc. should contain name of the service-provider (establishment), document number, name of the patient, name of the treating consultant, date on which product was purchased, name of the product/services availed, batch number, serial number, quantity, cost price of the product along with taxes (includes MRP and VAT) and signature of the authorized person.

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• Medical reports, bills, receipts, investigation reports, discharge summaries should be arranged in a chronological order.
• It is always preferable to indicate the receipts with a serial number for convenience and quick retrieval of the document, in-case it is  required.
• While filing the claim, all the receipts, bills, discharge summaries, investigation reports, consultation sheets etc. should be submitted in original. In addition, a set of xerox copies of the original documents need to be submitted too.

Remember, it is of utmost importance to retain a set of Xerox documents with the claimant, in-case the documents are misplaced or lost. This is vital for establishing proof of the medical treatment sought during the illness.

b) Get the claim form from the insurance company

• In order to file your health claim, the next step in the series is to get the claim form from the insurance company. Alternatively, the claim form can be downloaded from the official website of the insurer (or insurance company).
• Claim form is then filled which is usually self-explanatory in nature. In this claim form, queries such as the individual’s health-insurance cover details, reimbursement of the medical expenses statement details, purpose of hospitalization, personal details and identification proof and similar details are asked from the customer. Relevant and up-to date data must be submitted to avoid a goof-up in the process.

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• Claim form will carry additional instruction details which you must read carefully. It must be signed by you or the policyholder and by the treating consultant. The claim form should be stamped with an-official hospital seal for authentication of the claim process.
• After filling the necessary details, it must be accompanied with the relevant documents. These relevant documents can be further classified into 2 groups:

i) Medical Documents

ii) Policy Documents

i) Medical Documents

• Discharge Summary from the concerned hospital which contains name of the patient, date of admission, date of discharge, time of admission, time of discharge, main diagnosis and relevant investigations carried out during the hospitalization period.
• All the documents pertaining to the ailment for which the hospitalization was sought which incorporates first detection date of the ailment accompanied with solid/ample proof such as  physician’s consultation sheets, pharmacy bills or receipts, investigation reports, cash memos and proper prescriptions.
• Nature of the surgery or operation performed on the individual, information regarding the surgeon’s consultation fees, surgery fees, Operation theatre charges accompanied with relevant bills and receipts.
• Certificate from the attending medical practitioner / surgeon that the patient is cured or on the way to recovery.

ii) Policy documents

• Details about the previous policies accompanied with relevant proof of the policy documents, policy product receipts etc.
• Inception (beginning) of the policy-cover document (health-insurance policy) to indicate since when the patient is covered under the policy. The inception date of the policy cover makes it easier for insurance companies to deliver opinion on a particular claim.
• First health-insurance policy inception details must be provided to the concerned TPA (Third Party Administrator) for avoiding customer disputes and grieviances. This is an important step in the submission of policy documents and must not be over-looked.
• This claim document must be accompanied with TPA (Third Party Administrator) card for validation and verification purposes.

c) To prepare copies of the original for the purpose of claim submission

• Remember that while submitting the claim documents, they should be in original. In absence of original documents, claims will not usually be entertained.
• Along with original documents, an additional set of xerox copies must be submitted along with the claim form.
• Remember that these documents should be in serialized or chronological order.
• By doing so, the errors occurring in the claim process would be minimized. Keep an additional set of xerox copies for your own file as suggested earlier as proof in case the documents are lost or misplaced.

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d) Review and dispatch of documents

• After completing the compilation of the claim to be reimbursed, re-check your documents.
• Verify the documents and see that no document issued during the treatment process is missing. This is necessary to avoid a claim shortfall.
• Check whether all the documents (paperwork) are relevant to the treatment for which the claim is to be submitted.
• Ask the insurance company to which TPA the claim documents have to be submitted.
• Approach your local TPA (in your city or nearby city) where your claim documents are to be submitted.
• Discuss the submission process with the customer-care executive in the local branch of TPA in your city or town.
• Ask the customer care executive to check whether the submission of documents is appropriate or not. In case any modifications are to be made, note it down and follow the instructions as advised by the customer-care executive.
• After completing the pre-requisite formalities, the claim is then submitted to the Customer Care Executive in the concerned TPA.
• Inform the Insurance Company regarding the submission of the claim by sending a set of xerox-documents to them.

e) Understanding the fine print in the policy document

• Usually all health insurance claims have to be filed within 7 days of completion of treatment or discharge from the hospital.
• Remember that insurance companies will not honor claims in case the documents are not as per their terms and conditions.
• Understand that the entire medical expenses incurred during hospitalization may not be reimbursed to the policyholder.
• Make a note of the deductions or the medical expenses that are not included in the cover. Understand and get a clear picture of the entire process. This is of utmost importance as such expenses incurred as part of the medical treatment will not be reimbursed to the claimant.