Stuck with Medical Claim – Here’s the Easy Guide for you

By Sakshi Srivastava - 24 Jul 2021 Last Updated: 01 Dec 2021
Stuck with Medical Claim – Here’s the Easy Guide for you

A Health Insurance plan kicks in when the insured is admitted to the hospital or when the insured is faced with a medical emergency that costs money. A health insurance claim is stated to occur at that time if the hospitalization or medical expenses are reimbursed by the health insurance plan. Therefore a health insurance claim compensates the insured for expenses which are spent at the time of a medical emergency.

Therefore if you are doubtful as to what should be done in order to file for or claim Health Insurance, this blog will suffice all those requirements. We will intrinsically explain the step by step process and all the essentials regarding it, which can help you in filing for the Health Insurance claim, when you need one urgently without any hassle. So without any further ado, let’s learn!

Various Types of Health Insurance Claims

In a health insurance policy, there are two sorts of claims that can be made. The following are some of them:

  • Cashless
  • Reimbursement

Let's look at the meanings and processes behind both of these types of assertions.

Types of Health Insurance Claims

CASHLESS CLAIMS

When an insured gets treatment at a networked hospital, the claim is settled without the use of cash. A hospital that is connected to an insurance company is known as a networked hospital. Because the therapies are received at a networked hospital, the insurance company pays the hospital directly. As a result, you won't have to bear the financial burden of paying for medical bills on your own.

The methods to obtaining a cashless claim settlement are outlined below.

  • If you're planning on getting treatment, let your insurance company know ahead of time. At least 3 to 4 days' notice should be given before being admitted to the hospital. Filling out and submitting a pre-authorization paperwork to the insurance company is required. This is a claim notice form. In the event of a planned hospitalisation, the form should be completed and sent three to four days ahead of time.
  • If a medical emergency occurs and the insured is admitted to the hospital, the insurance company should be notified immediately, and the pre-authorization form should be submitted within 24 hours of admission.
  • The insurance company evaluates the claim based on the pre-authorization form and permits cashless claim payments once the form is filed.
  • The insured can then receive the necessary treatments without having to pay the medical fees.
  • The insurance company should get all medical bills, reports, and other medical documentation.
  • Original written documentation of such charges should also be presented to the insurance company if there are other expenses that are being covered.

REIMBURSEMENT CLAIMS

A reimbursement claim occurs when the insured pays his or her own medical expenditures and then receives reimbursement from the insurance company. Reimbursement claims will be made if the insured receives treatment at a non-networked hospital or if the insurance company does not allow cashless claim settlements.

The following are the steps to getting your health insurance claims reimbursed.

  • The insured must be admitted to a hospital that is not affiliated with the insurance company and get treatment there.
  • The insured should keep all of the original medical reports and bills. Medical expenditures should also be paid out of pocket by the insured.
  • The insured should get a Discharge Certificate or Discharge Summary from the hospital where treatment was received after being discharged.
  • The insurance company should subsequently receive this Discharge Certificate or Summary, along with a properly completed claim form, original medical reports and bills, and any other pertinent papers that the insurance company demands.
  • After that, the insurance company would examine the claim, the supporting documentation, and the costs incurred. After that, the expenses would be refunded.

Filing a Health Insurance Claim Form in Five Easy Steps

Filing a Health Insurance Claim Form

DOCUMENTS

Filling out the claim form should be very self-explanatory. It will inquire about stuff like:

  • Your member number, group plan number, or insurance policy number
  • Who was the recipient of the services? (for example if it was the primary insured or a dependent like a child, spouse or domestic partner)
  • If you have coinsurance or dual coverage, you should know about it.
  • What was the purpose of the visit (accident, workers' compensation, etc.)?

GET YOUR RECIEPTS IN ORDER

You'll need to request an itemized bill from your doctor. An itemized bill details every service delivered by your doctor, as well as the cost of each treatment. 3 Make sure that any prescriptions or drugs given to you as part of your treatment are itemized and listed. The actual itemized bills must be attached to the claim form by your health insurance company.

FILL OUT THE CLAIM

To receive a health insurance claim form, contact your insurance carrier or download a copy from their website. Your claim form will also include instructions on what other information your doctor or healthcare institution may want. It is recommended that you read it thoroughly before starting.

MAKE RELEVANT COPIES

Don't forget to make copies of everything once you've completed your claim form and received your itemized invoices from your doctor. It will help you avoid any claim-processing problems and make it easy for you to re-file your health insurance claim if it is misplaced. You should also look for medical inaccuracies in the billing codes and call your health practitioner if you have any questions. This step will prevent your health insurance from being denied due to erroneous information.

SUBMISSION AFTER THOROUGH REVIEW

Call your health insurance company and inform them you're going to send in your health insurance claim form to double-check everything. Examine all of your paperwork with them and ask if there is anything further you require. Also, find out how long you should expect to wait for your claim to be reimbursed from your insurance provider and put that date on your calendar.

Send the claim form to your insurance company after you have everything in order. The claim form should include the address to which it should be sent. Keep an eye on your calendar for the claim date you marked, and call your insurance carrier if you haven't received your claim within the specified time range.

Points to keep in mind-

The maximum amount insured

Only up to the insured's sum insured limit are health insurance claims allowed. If the claim exceeds the amount insured, the insured is responsible for paying the excess. As a result, the insured should check the health insurance policy's sum insured limit.

Exclusions

There are several situations that health insurance coverage does not cover. These are referred to as exclusions. If a claim is submitted for a cost that is not covered, the claim will be denied. So, before filing a claim, review the plan exclusions to ensure that no claim for a prohibited item is filed. Even if the claim is filed and then denied, the insured will be aware of the rationale for the denial.

The insurance policy's validity

Only if the health insurance policy is active and has not lapsed are claims settled. The claim would be denied if the coverage had expired. As a result, the insured should guarantee that the policy does not lapse in order to benefit from quick claim settlements.

Hospitals that are part of a network

Only treatments received at a networked hospital are eligible for a cashless claim settlement. So, if the insured wants to use the cashless claim service, they should check the list of affiliated hospitals before obtaining care. The list is easily accessible and searchable on the insurance company's website.

Timeline

In the case of a cashless claim, there is a deadline for submitting the pre-authorization form. The pre-authorization form should be filed 3-4 days ahead of time for scheduled hospitalization, and it should be submitted within 24 hours for emergency hospitalization. To get cashless claim settlements, you must adhere to certain deadlines. The claim may be delayed if the deadlines are not met.

The Benefits of Filing a Health Insurance Claim online

The advantage of submitting claims online on a website like ours is that payment for your claim may be much faster, up to 24 hours in some situations. Setting up an account to manage your services online is worth it if you want your procedure handled as quickly as possible. When you fill out your form online, you may be able to see what portion of your claim is covered, what your coinsurance clause is, and what deductible applies right away. Setting up an online account to access your health insurance benefits and claims can help you better understand the associated health insurance out-of-pocket payments, as well as what kind of refund or payment your benefits plan will provide.

Conclusion

In the end we can conclude with the fact that claiming for a Health insurance is not a process to be taken lightly. With the right mindset and proper following of the procedure along with keeping all the important factors in mind, it can be done without any hassle. We hope this blog provided you with incite full information. For more information on other related aspects, feel free to checkout our website.

By Sakshi Srivastava

24-Jul, 2021

Medical Insurance Related FAQ

Frequently Asked Questions

  • Why is it so essential to declare my pre-existing medical conditions?

    Patients are communicated to tell their physicians all about their medical history in order to get the best care, and health insurance policyholders are asked to tell their provider all about their pre-existing conditions in order to get the best coverage. Furthermore, if there are any inconsistencies in the medical insurance policy, the insurance company can cancel the policy.

  • What is the extent of medical insurance coverage in the UAE?

    The regional limit to which a health insurance policy's benefits are available is referred to as the scope of coverage. For example, in the UAE, health insurance with a definition of ‘Within the UAE' would only compensate policyholders for medical services received in the UAE.

  • Are family plans the cheapest health insurance available in the UAE?

    Family policies undeniably deliver some of the best coverage at the most affordable prices, making them one of the most cost-effective health insurance choices in the UAE. Even family health insurance policies, however, have their own limitations, such as a limited number of dependents and other constraints. When applying for a job, it is suggested that applicants spend some time reviewing the different inclusions and exclusions.

  • What are the Medical Insurance Policy for female in UAE?

    Medical insurance Policy for females are expensive because of the pregnancy related costs that occurs to the insurance companies. Whereas policy for female aged below 40 is too expensive compared to female aged above 40.

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