Navigating the Claims Process: Tips for Individuals with Health Insurance

Health insurance is not a new thing anymore. People are either covered under a medical policy or are planning to buy one. If you fall under either of the two categories, you must scroll down the blog to understand the claim settlement process involved under a health plan.

Working of a Health Plan

If you are planning to buy either individual health insurance plans or a family floater plan, you must first select the plan and the insurance company. You must select a plan which covers all your medical needs and provides maximum coverage at an affordable price. The goal of buying a health plan should be to protect your finances against any unfortunate health emergency. You must take a wise decision and analyse the benefits of the plan with the cost associated with it. You need to pay an annual premium for the coverage and the sum insured you select for yourself and your family. 

If you are an existing policyholder, then you must have paid an annual premium towards the plan. The premium depends on the sum insured you choose. After all the formalities, you must be aware of the process involved in filing the claim.

Claim Process of a Health Plan

There are two types of claim settlement processes involved in individual health insurance plans or any other plan you choose, one is the cashless claim, and the other is the reimbursement process. Let’s have a look at both the process separately:

Cashless Claim

In case of emergency admission into a network hospital, you have to follow the below-mentioned process: 

Step 1: Select a network hospital according to the condition of the insured. Try to choose a hospital near home.

Step 2: At the time of hospitalisation, you should present the health ID of the insured and fill out the pre-authorisation form within 24 hours to inform the Third-Party Administrator (TPA).

Step 3: After verifying your request, the TPA will start working on the claim by coordinating with the hospital.

In case of planned hospitalisation to a network hospital, here are the steps to be followed:

Step 1: You should select a network hospital for the treatment. 

Step 2: After selecting the hospital, you must inform the TPA at least 3-4 days prior to the admission of the insured.

Step 3: You must fill out a cashless request form at the network hospital

Step 4: Now, submit the form with other required documents (if needed).

Step 5: Once the claim is approved after the verification, TPA settles the claim by coordinating with the hospital itself.

Reimbursement Process

In case you choose a non-network hospital for treatment, you will not get the cashless facility. You will be eligible for reimbursement of the medical bills which you paid by yourself. Here are the steps involved in getting the reimbursement of the bills:

Step 1: The first thing is to get in touch with the insurer and provide them with the membership number.

Step 2: Settle all the bills of the hospital before making a claim request.

Step 3: You must attach all the bills, prescriptions, or any other required documents while making a request for reimbursement.

Step 4: Fill out and submit the reimbursement form, which is available on the website of the insurer.

Step 5: After the verification, the insurer either approves or rejects the claim.

Step 6: In case of approval, a cheque will be drawn by the insurer in the name of the insured.

Step 7: In case of rejection, you should file the claim again with a copy of all the required documents.

Points to Remember for Settlement of Claims

• You must keep all the medical bills safe till you get the reimbursement.
• The reimbursement form should be correctly filed with all the required documents.
• You must inform the TPA within 24 hours of hospitalisation in case of cashless treatment.
• In case of reimbursement, a claim request must be submitted within 7 days of discharge.
• As a claim settlement process involves layers of verification and documentation, you must remain honest with the insurer.

To Sum Up

To avoid the unnecessary to and fro, you must choose an insurer which provides a smooth process for claim settlement. One such insurance company is Niva Bupa. It has a high customer satisfaction ratio and has delivered quality service for years. If you plan to switch your current health provider, you must visit the website of Niva Bupa to check their individual health insurance plans along with various other healthcare insurance services. By selecting Niva Bupa, you just have to sit back and relax, as all your insurance needs will be taken care of by the company.