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Claim Settlement Methods of Health Insurance Research Team | Posted On Friday, May 25,2018, 07:08 PM

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Claim Settlement Methods of Health Insurance



Claim settlement means when your claim is honoured. When your insurer covers your hospitalization expenses, your claim is said to be settled. There are two methods of claim settlement in Health Insurance. They are as follows:

1)   Cashless facility: Under this method, the insurer settles your hospitalization bills directly with the hospital. In this case, you need to get hospitalized only at a network hospital. The claim settlement is fast.

2)  Reimbursement: You pay for hospitalization expenses upfront and get reimbursed by the insurer on discharge from hospital and submission of necessary documents. You can opt for any hospital but the claim settlement will take time.

If you had opted for a plan with a cashless facility, but got treated in a non-network hospital, then the cashless facility ceases to apply. Therefore, your expenses will be reimbursed instead.

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Claim Settlement Methods of Health Insurance:

The process of claim settlement:

It is a misconception that Claim settlement is a tedious process. But it can be hassle free if you are aware of the process which is given as below:

1) Cashless Method of Claim settlement:

In case of a cashless claim, follow the steps given below:

Step 1:

Check whether the illness is covered in your health insurance policy. Next, check if the hospital is a network hospital.

Step 2:

Inform your insurer about the hospitalization within 24 hours. You will be asked to fill a Pre-Authorization Form and submit it at the TPA (Third Party Administration) counter at the hospital. They will in turn forward the form to the insurer for approval.

Step 3:

You will be required to submit documents like Cashless Health Card provided by the insurer and some other KYC documents for identity.

Step 4:

If insurer approves your claim, he will retain the original hospitalization documents. Keep a copy of the documents for your records.

Step 5:

Retain the pre and post hospitalization bills and associated prescriptions/medical reports to claim them later. Generally, these expenses are reimbursed. It is advisable to check for this in your Policy Document.

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2) Reimbursement Method of Claim settlement:

Reimbursement is done if you have not opted for cashless facility or if you are treated in a non-network hospital. Following are the steps to be followed in this case:

Step 1:

Inform the insurer. Fill and submit the reimbursement claim form within 30 days from the date of discharge. This form is available with the insurer.

Step 2:

Get the original copies of medical reports, medicine bills and hospitalization bills stamped and signed and submit them along with the claim form. The hospital bills should have the Registration No. of the hospital. The report should mention your name and date of hospitalization. Also attach doctor’s certificate declaring your medical condition and the prescription advised on hospitalization.

Step 3:

Submit the Discharge Summary/Card to the insurer.

Step 4:

Submit your doctor’s follow-up prescription in original to the insurer. Submit post hospitalization expenses bill within 30 or 60 days from discharge as per the terms of your policy.

Step 5:

Retain copies of all the submitted documents for future reference. Your claim will be settled within 2-3 weeks.


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