Health Insurance Claim Process: Reimbursement & Emergency

14 Mar 2022  Read 1526 Views

A health insurance claim, also sometimes called medical insurance claim, is a plea application made by the policyholder or the insured for reimbursement of expenses that were incurred for the treatment of an incident covered in the policy.

The process of settlement of the insurance claim depends on the type of insurance policy you have opted for. Once the insurance company verifies the claim, it could either pay the sum directly to the hospital or reimburse you the amount you spent on treatment.

A lot of people know of the existence of health insurance, but this knowledge is quite surface level. Not a lot of people know what goes on when the insurance needs to be claimed in case the insured event takes place. So today's article shall serve you, dear reader, in getting to know the nitty-gritty of the health insurance claim process.

What is a Health Insurance Claim?

Before we get into the technical details of the blog, let's better understand what a health insurance claim is, yeah?

Raju was very sad. You know who Raju is, right? Apna Rastogi. Paralysed postmaster father, ailing mother and unwed Kammo. Once the Postmaster’s body stopped working partially and his salary completely, the family was in hot deep water. Raju didn’t earn yet, and all of his mother’s salary was spent on his father’s medicine. What could they do but didn’t, to get out of this situation? 

*Dramatic drumrolls, please!* Health insurance.

 If the postmaster had health insurance, the family wouldn’t have had to make ends meet with a pitiful sum of ₹2500. They could buy bhindi. Hell, Kammo would even be married by now!

A sad twist though, what if the Postmaster did have health insurance but Raju didn’t know how to claim it, or worse, what if the company didn’t honour the claim when the hour demanded? 

But we swear on Postmaster sahab today, that we will get Raju out of this. Let us save him from the trap then, shall we? 

What does an insurance claim do?

When I went for my second Covid-19 jab, there were two ladies sitting and sobbing beside an ill man in his 50s. I could not understand what was so wrong since the man looked, well, not dead. So I asked the nurse about it, and she said the man needed an urgent operation. Even after selling their land, they could not afford it so they simply sat there to watch him die. Neither could the hospital help the situation nor could they.

Insurance claims protect people from a financial tornado that could stir up their lives left, right and center. If you have been in a place where either you or a family member has been in an accident or any health-related incident occurred, you know exactly how much of your financial resources get drained. Insurance claims help assist people to get back on their feet after suffering a massive setback.

Good faith and Bad Faith Insurance Claim

But there is such a concept as ‘utmost good faith’ and ‘bad faith’ in insurance. 

The contract of Uberrimae Fidei states that both the insured and insurer have to disclose all necessary information that could, in any way, influence decisions related to the policy. A failure in doing so is a reason good enough to declare the agreement void by either party. 

In contrast, bad faith is used for the insurance company in a situation when it does not properly adhere to the responsibility of thoroughly and quickly investigating the claim or they refuse to pay a genuine claim. It is not only their moral responsibility, but they are also bound by law to investigate sincerely. 

It is not very difficult to figure out if your insurance company is trying to find a way out of claim settlement or not. If even after providing all bills and supporting documents for your claim, the company rejects it, it is operating in bad faith in the eyes of the law.  

Types of health insurance claims

Primarily, the health-related expenses that usually occur in a person’s life are prescription medications, hospital stays, surgeries, or emergency medical attention. 

When these expenses are covered in the insurance policy, the insurance company can settle the claim in either of the two ways-

👉 Cashless Claims

👉 Reimbursement

Cashless Claim process

In this type of claim, the insured can avail treatment in any of the network hospitals of the insurance company and the company will take care of the payment of bills. A network hospital is a hospital that is in agreement with the insurance company to provide cashless treatment to the insured once they produce their health insurance card. In most cases, the claim for settlement of the bills is approved within four hours since insurance has been claimed. 

It is very important to understand the scope of your medical insurance before you go about enjoying your life as it is. If you do anything intentionally that causes you harm or in any way, violates the terms of policy, the insurer will not be hesitant even for a second to reject your claim. 

There are two ways to go about it. 

Claim process for planned treatment:

There are times when you have already been informed by the doctor regarding any procedure you need to undergo. You usually have days before it actually happens. It is better to fill out the claim form and inform the insurance company 3 or 4 days prior to the procedure so that when it is time, your work gets done hassle-free. 

Claim process for emergency treatment:

Not all health issues send an invitation so that you can RSVP to it on time. Some diseases come unannounced and take away a heavy chunk out of our pockets. In case of an emergency admission into the hospital, the closest family members are supposed to handle the cashless claim. Meaning they are to contact the insurance company with all the details they have of the policy and provide the necessary documents to initiate the process. The customer service will in return direct them to their network hospital where the rest of the process will be completed mutually between the hospital and the company. It is thus advisable that when you buy a health insurance policy, you should inform your family about the mediclaim number, insurance coverage and all major details related to your policy.     

Claim through the reimbursement process

This claim process, as I personally feel, is like playing Khatron ke Khiladi (lite). In this, you are supposed to pay the expenses that were incurred during an incident, be it planned or emergency, and later, you will be repaid the whole sum on verification of the documents. In cases like this, it is not necessary that you have the option of going to a network hospital only. You could go to any hospital of your choice and get treated. All you have to do is keep the original receipts and later stage them to the insurance company. If the bills are not original, it is very likely that your claim will get rejected. 

What happens when your claim gets rejected? Saare paise gaye!

Since there are so many grounds for your insurance to be void or your claims to be rejected, it is essentially essential to choose the right health insurance provider that does not back off its responsibility. 

This is how the Postmaster should have evaluated the process. What, you forgot about Raju? 😏

It’s settled then…

Having health insurance is important; but, getting the claim settled is more important. 

The postmaster’s story might be fiction, but the man who laid on that hospital bed was very much a reality. Raju might not be that helpless but those two ladies were.

“Prepare and prevent, don’t repair and repent.” We get insurance not because we expect a mishap, but because we would rather be prepared when it does occur. Insurance does it so that our pockets don’t suffer as much as we do in a medical emergency.  

We go to extremes to save our family from even teeny-tiny harm. Isn’t it only fair that we take this teeny-tiny step to get insured against it? 
 

About the Author: Rishika Mukherjee | 239 Post(s)

Mukherjee is an avid reader and loves to write as much as read. As Hazel Grace stated, she could read a good author's grocery list, and so would Miss Mukherjee. 

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