Cashless and Reimbursement Claims:  Health Insurance Claim Process

Cashless application process:

To benefit from the cashless claim option, the insured person must be treated in a staffed hospital. By providing the health insurance details and presenting the electronic card or other physical proof of the health insurance purchased on behalf of the insured, the insured can benefit from hospitalization and cashless treatment. if the illness/injury is covered by the policy. Once the patient is discharged from the hospital, all medical bills are sent from the hospital to the insurer. The insurer then evaluates the costs and pays the payment.

The procedure for obtaining treatment at a cashless network hospital depends on the type of treatment, planned or unplanned. Unplanned medical treatment at a cashless network hospital usually takes place in an emergency.

• Procedure for reporting the treatment provided in the cashless network:

As a general rule, the insured must inform the insurer prior to hospitalization or treatment required for cashless treatment. The company must be informed at least 4 days before the treatment appointment. A cashless application form should be sent to the appropriate insurer address, primarily by post, email, or fax. For more information, you can contact the customer service of your mutual. Once these steps have been completed, the insurer will inform both the insured and the hospital in the question of the insurance coverage and eligibility. On the day of hospitalization, the insured must present their health card and confirmation letter. Medical bills are paid directly to the hospital by the insurer.

• Cashless Claims and Health Insurance Reimbursement:

Procedure for requesting emergency treatment in the cashless network: The policyholder can contact the insurer’s customer service department for information on the nearest network hospital. By showing your health insurance card, you can benefit from a cashless hospital stay. The hospital must complete the cashless claim request form and send it to the appropriate insurer address, primarily by mail, email, fax, or through customer service. The insurer then sends an approval letter to the hospital stating the insurance coverage. Medical bills are paid directly to the hospital by the insurer. If the claim is denied, a letter will be sent to the insured stating the reasons for the denial.

Reimbursement process:

The claim for medical insurance reimbursement can be made if the insured chooses to go to a hospital of their choice that is an empty hospital. In this case, the cashless claim option cannot be used. Therefore, the insured person must pay all their medical bills and other costs related to hospitalization and treatment and then request reimbursement. To benefit from the reimbursement request, you must provide the insurer with the necessary documents, including original invoices. The company then reviews the claim to see if it is covered and then makes a payment to the insured. If the treatment is not covered by the policy, the claim will be denied. The insurer usually gives the reasons for the rejection.

Documentation:

The following documents are required to complete one:

• Complete form
• Medical certificate/form signed by the treating physician.
• Discharge summary or card (original) provided by the hospital.
• All invoices and receipts (original)
• Pharmacy/hospital prescription and cash tickets.
• Investigation report
• If it is an accident, the FIR or Medical Legal Certificate (MLC) is required.
• GST rate of 18% for all financial services as of July 1, 2017.