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The perfect medical claim

Tinesh Bhasin in Mumbai | March 30, 2009 12:38 IST

Medical insurance is bought as a protection against an unforeseen health expenditure. But that's just half the work done. The other half actually begins when any illness is detected. Customers blame insurance companies and agents when the entire claim or a part of it is rejected due to lack of documents.

"Insurance companies settle the claims only on the basis of the paperwork," says Gaurav Mashruwala, a certified financial planner.

Let's look at a few things that will help you to make a hassle free claim.

When you are diagnosed with an illness and are likely to make a claim, intimate your insurer. Insurance companies provide a helpline number on the insurance card that comes along with the policy. You should also inform them through fax and email. This intimation should just mention your policy number and illness.

The insurance company or its third party administrator will get in touch with you. You will be guided to a network hospital. TPAs will also tell you about the terms and conditions of the policy, in case you have missed the fine print.

In case of an emergency hospitalisation in a non-network hospital, insurance companies give 24 hours for you to inform them. Network hospitals, typically, inform TPAs on their own.

A network hospital does not necessarily mean that the procedure will be cashless. Many renowned hospitals that are a part of an insurance company's network may still require you to pay in cash. Also, the biggest insurers -- public sector companies -- do not have a 100-per cent cashless facility.

In case of a non-network hospital, the company will require a copy of the hospital's registration certificate when you submit the documents for a claim.

Some companies, such as ICICI [Get Quote] and Bajaj, pay only 80-90 per cent of the hospital bills in case the treatment is done in a non-network hospital. This is called co-payment.

When a person has to shell out cash initially, the smallest of details need to be taken care of for a smooth settlement.

  • Each bill, whether medical or investigation (tests), needs to have supporting evidence. The insurer requires the original copy of test result and the doctor's slip asking you to conduct the test.
  • bill should carry the name of the patient as well as the doctor's. Same goes for the investigation reports. If both the requisites are not fulfilled, the insurance company may reject the bill and the report.
  • The name of the patient should be mentioned on the bills in the same way as it is stated in the insurance policy documents.
  • The most important piece of document is the discharge certificate. 
  • All insurance companies require the bills with subheads. This is necessary as insurers have a cap on some expenses. For instance, National Insurance Company gives only 20 per cent of the sum assured as doctor's fee and up to 50 per cent on medicines.
  • Copies of the documents should be submitted to a TPA within seven days of discharge. All original bills need to be submitted to the TPA. 
  • While submitting the bill, make a covering letter and attach a copy of the policy. It should also have a doctor's note describing the illness. Also, include a copy of the pre-authorisation from the TPA and a copy of the insurance card.
  • When you submit the bills, take acknowledgement that the TPA has received the bills.
  • In case of post-hospitalisation charges, do make a note of it in the claim. Ask the TPA what is the prescribed time limit to submit the relevant documents.

Having an insurance policy does not mean that you should be carefree with the charges hospitals levy. Keep a track of them. Each policy has a finite sum assured. You will need to pay the additional amount.

Try and save on the bills as much as possible. During the remaining tenure of the policy, the disease may relapse or the insured may face another emergency.

Hospitals usually give a discount if you bargain with them. "They reduce charges, such as nursing, room and investigations," said an insurance broker.

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