A large number of mediclaim policyholders have to claim reimbursement from their insurance companies for hospitalisation expenses, as a large number of hospitals have been removed from the list of network hospitals by the public sector insurance companies.
Most government-owned insurance companies (and some private insurance companies) require you to deal with a third party administrator (TPA) to make your claim, adding one more layer in the claim process. At the best of times, it takes at least 2-4 weeks for the claim to be settled.
Here is the list of eight thumb rules to claim your amount properly:
Inform the company about the impending claim via email
1. Inform the company about the impending claim via email to the TPA (or the insurance company) as soon as you are hospitalised. The said email format is available on the policy documents as well as the booklet that comes along with the card that you get for each policyholder.
The email sent by you must contain the full details of the policy number, date of insurance policy, date from which the policy was first taken from the insurance company, name of the policyholder, brief details of the reason for hospitalisation as well as the details of the concerned hospital.
If hospitalisation is due to an accident
2. Make sure that you take a print out of the same email and forward it by hand or courier and get the stamped acknowledgement on the physical copy as well. If you are using your agent to do this, don’t just depend on him to verbally inform the TPA. Make sure you get the acknowledged copy of the claim intimation email.
3. If hospitalisation is due to an accident, then you will need the certified copy of the first information report (FIR) filed with the police. If the accident was at home, which does not involve the police (say you slipped and fell in the bathroom at home), get your treating doctor to certify in another letter that the injuries are consistent with your claim that they were incurred in a domestic accident.
Get all original bills and reports
4. Get all original bills and reports and discharge certificates and submit them along with the claim (you need to make copies for yourself). Most TPAs nowadays demand copies of the indoor case papers of the hospital. The hospital will supply you with a certified copy of the indoor case papers on payment of a small fee.
Also, get copies of any X-ray or MRI films (again available on payment of a small fee to the hospital), since some TPAs have started demanding the X-ray/MRI films as well.
Make sure that any bills for diagnostic tests or medicines are supported by a prescription
5. Make sure that any bills for diagnostic tests or medicines are supported by a prescription contained in the indoor cases papers or a separate prescription from the treating doctor. Number all the documents/pages in the claim file. If possible cross reference all expenses and reports with the relevant prescription and bills. Keep copies of all documents submitted to the TPA and get acknowledgement from them in writing for any documents submitted.
6. Make sure that the claim is submitted within 1-2 days of discharge from the hospital to avoid the chances of the claim being denied on grounds of delayed submission. If you have post discharge claim amounts (such as medicines prescribed on discharge to be taken for a few weeks or months after the hospitalisation) you can submit a supplementary claim later.
Keep track of your claim status on the website
7. Keep track of your claim status on the website. Most TPAs have online claim status on their websites though, for obvious reasons, they do not publicise it too much.
The TPAs have a disconcerting habit of posting fresh requirements regarding your claim on their website without ever actually sending the letter to you. You will need your policy number to be able to find out the status of your claim.
Every second follow up should only be by email or by acknowledged letter
8. Every second follow up should only be by email or by acknowledged letter. This helps build up your case in case any future action is required.
If you follow all these steps, hopefully, you will get your claim amount relatively quicker and will not need to use the grievance redressal forums provided by Irda as well as consumer legislation and the regular courts.
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