Master The Art Of Mediclaims

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Insurance companies settle claims only on the basis of documentation. Hence, this has to come into place properly right from the moment an illness has been detected and treatment advised. Moreover, these companies are tough to please and the claim will not be passed if all the requisite paperwork is not in order. Let’s start by looking at a few areas that will help you towards achieving a hassle-free claim. When you are diagnosed with an illness and are likely to make a claim, intimate your insurer on the helpline number given on the insurance card that comes along with the policy. Also, make it a point to have written communication via fax or e-mail.

This intimation should mention your policy number and illness and be in the prescribed format. Subsequently, the insurance company or its third party administrator (TPA) will get in touch with you and you will be guided to a network hospital. TPAs will also tell you about the terms and conditions of the policy, the insurance cap, if any, for your ailment and any restrictions in case you have missed the fine print. In case of an emergency hospitalisation in a non-network hospital, insurance companies give you 24 hours to inform them.

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 (and get reimbursed later) if your case is complicated or there is a chance of a pre-existing illness. Moreover, many of the public sector companies do not have a 100-per cent cashless facility. Generally, clients face more problems when it comes to making a claim after having being treated in a non-network hospital, especially if the claim is rejected due to improper documentation. For a smooth settlement, the smallest of details need to be taken care of.

Some of the key points to remember are:
a) In case of a non-network hospital, the insurance company will require a copy of the hospital’s registration certificate when you submit the documents for a claim.
b) Each bill, whether medical or investigation (tests), needs to have supporting evidence. The insurer requires the original copy of the test results, the doctor’s slip asking you to conduct the test and the invoice of payment made. So, for instance, if you are planning to make a maternity claim under a group health company cover keep all the relevant reports such as that of sonography etc from the start of the pregnancy. All original bills and test [PAGE BREAK]

reports need to be submitted to the TPA within seven days of discharge.
c) Each bill should carry the name of the patient as well as that of the doctor. This is true of investigation reports too. If both the requisites are not fulfilled, the insurance company may reject the bill and the report.
d) The name of the patient should be mentioned on the bills in the same spelling as it is stated in the insurance policy documents.
e) All insurance companies require an original copy of the discharge certificate. Moreover, the information mentioned in the discharge certificate should be uniform all across.
f) Insurance companies require bills with subheads. This is necessary as insurers have a cap on some expenses. For instance, many insurance companies restrict the room charges per day to 1 per cent of the insured amount while many PSU companies such as National Insurance Company give only 20 per cent of the sum assured as doctor’s fee and up to 50 per cent on medicines.
g) While submitting the final 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 insurance card and a pre-authorisation request from the TPA if possible. Make sure you take an acknowledgement from the TPA about the submission of bills.
i) In case of post-hospitalisation charges, make a note of it in the claim and ask the TPA about the time limit for the submission of the documents.