How do I make a claim of my insurance policy? How long will it take to get the final settlement?
The general procedure for making a cashless claim is as below.
Procedure to File a Claim for Planned / Emergency Hospitalisation:
Network hospitals will provide the cashless facility to individuals who have selected ‘claim processing by TPA’. The insured individual can undergo treatment in network hospitals provided that the TPA (Third Party Administrator) has given the authorisation in advance.
The list of network hospitals can be accessed at the insurer’s official website. The same website can be accessed to download the request from which should be filled in with the requisite details and submitted to the TPA so that it can approve and authorise the same.
When the TPA receives the request form along with other related medical details from the network provider or the insured individual, it will provide the network hospital with the pre-authorisation letter once it has verified the information received. At the time of discharge from the hospital, the insured individual will have to sign the discharge documents following verification and he / she will also have to bear inadmissible and non-medical expenses. If the insured individual cannot provide the necessary medical information, the TPA holds the right to decline pre-authorisation. If the medical insurance claim is declined, the insured individual can undergo treatment based on the advice of the treating doctor after which he / she will have to furnish the relevant claim documents to the TPA so that claims can be reimbursed.
In case of reimbursement of expenses:
To have claims reimbursed, the insured individual will have to furnish the relevant claim documents to the TPA prior to the due date prescribed in the policy. The insured individual can undergo treatment based on the advice of the treating doctor. The company will not cover costs related to the treatment of the insured individual neither before nor during the treatment. The insured individual will have to bear all costs incurred for the treatment. The insured individual will also have to furnish the bills along with the other relevant documents to the company / TPA for the reimbursement of claims.
The documents that must be furnished when claiming reimbursement from the company / TPA include the original claim form disclosing all the necessary details, payment receipts, original bills, hospital discharge certificate, original hospital cash memo, prescription from the chemist, investigation test reports along with the attending doctor / medical practitioner’s prescription, original payment receipt, certificate related to diagnosis and bill receipts from the attending doctor / medical practitioner, certificate from surgeon disclosing the plan or nature of operation underwent by the individual along with the diagnosis certificate supported by bills, and any other document as required by the TPA or the company.
If the company accepts the insured individual’s settlement offer, the customer will receive the payment within seven days after the offer has been accepted. In case there’s a delay in making the payment to the customer, the company will usually pay interest higher than the bank rate.
In case the company rejects the claim of an insured individual for any reason whatsoever, it will communicate the same to the individual in writing within 30 days after it has received the final document.
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