How to Claim for Care Insurance in India

Care insurance, more popularly referred to as health insurance, is one of the key financial instruments to cover medical expenses arising in India. The moment this happens, you are supposed to know how best to go about the process of claiming your care insurance so that the whole affair does not cost your time, money, and peace of mind. This all-inclusive guide shall be of help to you through the claiming process of your care insurance in India, under different contingencies.

Understand Your Care Insurance Policy

Essential information related to a care insurance policy before proceeding for claims:

1. Covering Detail: Know everything the policy does and does not cover; it also includes coverage for hospitalization expenses, preand post-hospitalization expenses, day-care procedures, and specified illnesses/diseases and their treatments.

2. Network Hospitals: Take a note of the list of network hospitals where one can get cashless treatment.

3. Claim process: Understand the difference between cashless and reimbursement claims and in which case each applies.

4. Documentation requirement: Normally understand what documents are generally required to be submitted along with a claim.

5. Policy exclusion: If there is any waiting period or exclusion in the covered policy.

Types of Care Insurance Claims

There are basically two kinds of care insurance claims in India:

1. Cashless Claims: The insurance company settles them directly with the hospital to avoid out-of-pocket expenses for the policyholder.

2. Reimbursement Claims: The policyholder has to pay for the medical expenses first, following which he can file a reimbursement claim with the insurance company.

## Cashless Claim Process

### Step 1: Choose a Network Hospital

Choose a hospital from the network of healthcare service providers enlisted by your insurance provider. It will ensure that the cashless claim process goes smoothly.

Insurance Information, Pre-authorization, and Admission

### Step 2: Inform Your Insurance Company

Planned Hospitalization -Inform your insurance company about the same at least 48 – 72 hours in advance. Emergency Hospitalization -Inform the insurer within 24 hrs of admission.

### Step 3: Present Your Health Card

Present your health card at the insurance information desk of the hospital along with valid photo identification.

### Step 4: Fill the Pre-authorization Form

Fill up the pre-authorization form provided by the hospital that includes general information about your policy, the nature of illness/injury, and the approx. cost of treatments.

### Step 5: Approval Process

The hospital then sends the pre-authorization form to your insurance company. The insurance company would verify all the details and approve the cashless claim if everything is okay. This, in general, takes around 4 to 6 hours.

### Step 6: Go for Treatment

You can go ahead and undergo the treatment without paying any money towards it, except the excluded costs under your policy.

Step 7: Discharge

At the time of discharge, you will be asked to sign the bill. You must pay all those expenses which are excluded under your policy.

Reimbursement Claim Process

### Step 1: Intimate Your Insurance Company

Intimate your insurance company about the hospitalization immediately – preferably within 24 hours of admission.

Step 2: Collect all the documents required. Usually, all of the following are included:

Duly filled claim form

Bills and receipts original

Discharge summary

Investigation reports

Prescription

All other medical documents regarding the case

### Step 3: Submission of Claim

Within the submission timeline, normally 15-30 days from the date of discharge, submit all the collected documents to your insurance provider.

### Step 4: Processing of the Claim

The submitted documents will be verified by the insurance provider, and they will settle the claim accordingly. It may take anywhere between 15 to 30 days.

### Step 5: Claim Settlement

If approved, the reimbursement amount will be credited to your bank account.

## Tips to Make Sure Your Claim Is Processed Smoothly

1. Keep policy details handy: Always carry your health insurance card and have your policy number at your fingertips.

2. Understand Your Policy Limits: Know about the sub-limits on room rent, specific treatments, or procedures.

3. Keep Complete Documentation: Keep safe all original bills, receipts, and medical reports.

4. Follow Up Regularly: Check periodically with your insurance company or the TPA regarding the status of your claim.

5. Be Honest and Accurate: Ensure that any document which you need to fill out in connection with your claim carries true and correct information.

Common Reasons for Claim Rejection

Knowing some of the common reasons for the rejection of claims will help you avoid some pitfalls. Here are a few:

1. Non-disclosure of pre-existing conditions: Disclose all your pre-existing conditions at the time of purchasing the policy.

2. Claim filed too late: File a claim within the stipulated time period.

3. Inadequate documentation: Ensure that all necessary documents are submitted.

4. Exclusion in the policy: Know what your policy does not cover.

5. Inadequate duration of hospitalization: Some policies have a minimum no. of days of hospitalization without which claims are not payable.

What to Do If Your Claim Gets Rejected

If a claim under care insurance gets rejected, then don’t lose all hope. Here’s what you can do:

1. Understand the reason: Ask your insurer to explain in detail the reason for which the claim has been rejected.

2. Review your policy: Recheck with your policy terms if the rejection is justified.

3. Supportive evidence col­lect: If you feel your case was unfair to be rejected, then collect any other documents that will help prove your claim.

4. File an appeal: Most of the insurance companies have an internal complaint redressal mechanism. You need to file a formal appeal with your insurance company.

5. Insurance Ombudsman: If your appeal gets rejected, then you may approach the Insurance Ombudsman of your region.

Conclusion

Actually, claiming care insurance in India is daunting, but once the process is understood and one gets prepared for it, all will really go smooth. Always read your policy document carefully, keep all the necessary documents organized, and never hesitate to reach out to your insurance provider in case of doubts. Your health insurance is meant for financial security during medical emergencies; hence, make use of it effectively whenever the need arises.