How to Make a Claim When You Have a Health Insurance Plan?

Do sky-high medical expenses destroy your peace of mind? Do you suffer from constant stress regarding mounting hospital bills? Well, a good health insurance plan may exactly be the thing that you need. Now, let us take a look at the various aspects of a health insurance plan.

What is a health insurance plan? 

Health insurance is a form of insurance that covers our various expenses in case of an illness or a medical emergency. Although covers vary from policy to policy, the basic coverages provided are hospital fees, costs of medicines, doctors, and consultation fees. There are certain policies that may cover transportation costs, like ambulances since they are a medical necessity in case of an injury, but the particulars differ from one company to the other.    

Types of health insurance plans-

Health insurance plans can be broadly divided into two segments, which are

  • Mediclaim plans- These are the most common type of health insurance plan, wherein the insurance company covers your cost of treatment at a hospital. The cover includes everything from medicines, to consultation fees, medical tests, etc. You can claim a payout once the treatment is finished by submitting the bills. These insurances usually come with an upper limit of expenses. 
  • Critical illness health insurance plan- These are specialized health insurance plans that cover specific life-threatening illnesses like cancer, etc. The payout is decided by the insured and not on the basis of hospital bills since the treatment for these diseases can last for a very long time and require extensive care to recover from. Certain diseases can be potentially life-altering and these policies come in extremely handy in these cases. Another benefit of these policies is the fact that the payouts can act as an income substitute when one is unable to work due to illness. 

How to make a claim?

Health insurance plans usually have two methods of claim disbursal, cashless basis, and claims on a reimbursement basis. This depends on the type of policy that the customer opts for. Now, let us take a detailed look at how one can get a clai

  • Cashless-
  • If you are suffering from an ailment and hospitalization is necessary, do check with your TPA [ Third Party Administrator] and identify a suitable hospital in your vicinity that has an agreement with them.
  • Once you are at the hospital, fill up the pre-authorization form that is available at the claims counter of a hospital or by downloading it from the TPA website. Here, you can specify the type of cover you are opting for, and the TPA will get back to you with the permissible sanctioned amount and the clearance. 
  • Submit your documents for verification with your TPA for KYC and identification purposes. They may retain a copy of your documents for further reference. 
  • Refer to your health insurance plan for pre and post-hospitalization covers and then you can commence the treatment and your TPA will take care of the rest. 
  • Reimbursement claims- 
  • Get in touch with your insurer and apply for a claim within 30 days of your discharge date.
  • Attach all the required documents like medical bills, hospital bills, prescriptions, test charges, etc. The documents should carry the registration number of the hospital along with the details of the patient. Make sure to submit a prognosis prescription clearly stating the fact that the hospitalization was not voluntary and was done on the advice of a certified doctor. 
  • Make sure to submit a fitness certificate and in case of post-hospitalization care, do submit the required documentation within the time frame given by your insurance company. 
  • Once the claim is admitted, it will be settled within 2-3 weeks. It is advisable that you retain all the relevant documents for future reference.

You can claim a medical insurance policy easily by following these steps. We recommend that you carefully go through the policy documents for a better understanding of the terms and conditions so that you can have a seamless experience. 

Now, let us look into the factors that you should consider while selecting a health insurance policy. 

  • Consider how many illnesses are being covered by the insurance policy.
  • The flexibility that is being provided by the policy.
  • Degree of changes in premiums over the course of the insurance cover.
  • A very large and comprehensive network of hospitals, health centers, clinics, nursing homes, etc.
  • Senior citizen and old-age benefits that are being provided.

If you are confused about which policy to opt for, a mediclaim or a critical illness cover, we would like to point out that they serve quite different purposes and cannot be a good substitute for each other. That’s why it is always recommended that you get both so that you are adequately covered from all dimensions and risks. 

Final take:

A good health insurance policy can be a lifesaver when you need it the most, and knowing how to claim one in case of an emergency is extremely crucial. Please take into consideration all the factors that were stated while selecting the right insurance policy for you and your family. 

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