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6 Things to Consider Before Filing Your Health Insurance Claim

Team AckoJan 17, 2024

Like car insurance, health insurance is also meant to provide financial cushioning in case of mishaps. Unlike car insurance, health insurance is not mandatory. As a result, people often perceive it as an expense rather than a precautionary measure. This approach leaves a major part of the population without a health cover. Even, those who have a health insurance cover might not be well-versed with the details regarding raising a claim. Claim settlement is the most crucial aspect of medical health insurance for the policyholder.

Before

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6 Things to Consider While Filing Medical Health Insurance Claim

1. Tenure

Mr. Suresh was admitted in the hospital as he was severely hurt after falling down from the stairs. Fortunately, he had purchased a dedicated Personal Accident Cover health policy. Being from a modest background, his family felt comforted knowing that there was an insurance policy to take care of the expenses. However, Mr. Suresh and his family were in for a shock as the insurance company refused their claim request because the policy was expired.

You must manage your health insurance actively so that you are covered all the time. An expired policy is considered as an inactive policy and no insurance company will settle a claim request raised in case of an expired policy.

Also read about: Family health insurance plans

2. Mediclaim vs Health Insurance

It is common to get confused regarding, Mediclaim and health insurance. Some people use Mediclaim and Health Insurance interchangeably. However, there is a difference in coverage when it comes to these policies. Whether it is a Mediclaim policy or a health insurance policy, you must be aware of the coverage and raise a claim accordingly.

Going through the inclusions and exclusions of a health insurance/Mediclaim policy will give you an idea whether the condition against which you plan to raise a claim is covered by your policy or not. If you are not sure, you can get in touch with your insurer to get your doubts clarified.

3. Terms and conditions

Merely knowing the inclusions and exclusions isn’t enough. Your claim request won’t be approved if the condition for which you are raising a claim is disqualified as per the terms and conditions of the policy.

4. Intimating the insurance company

If you are going for planned hospitalization and cashless claim settlement, it is suggested to intimate the insurance company seven days prior to hospitalization. In case the policyholder is hospitalized in an emergency situation, such admission must be notified within 24 hours for a smooth claim settlement process.

5. Reimbursement Claims

If the policyholder is admitted in a non-network hospital, then the insurance company shall settle the claim on reimbursement basis. In such cases, the policyholder needs to submit all necessary documents within 7 days of getting discharged from the hospital.

Documentation:

  • Claim application

  • Discharge card

  • Bills

  • Reports

  • Prescription details

6. Proper Communication

Ensure proper communication with the insurance company. Almost every claim is different in some ways. There might be certain complications in a case which do not exactly fit well with the existing process of an insurance company. Therefore, two-way communication is extremely important. You can do your part by communicating upfront with the insurance company and being patient regarding their response. Also, answer all their queries truthfully and comply with them regarding the claim settlement process.

Things to avoid when filing health insurance claims:

  • Delay in Notification: Avoid delaying the notification of your medical treatment or hospitalization to your insurance provider. Notify them promptly, especially for planned treatments or surgeries. Delayed notifications may lead to claim rejections.

  • Incomplete Information: Ensure all information provided on the claim form is complete, accurate, and legible. Incomplete or incorrect details can result in claims being denied or delayed.

  • Missing Documentation: Avoid failing to provide essential supporting documents, such as medical bills, prescriptions, diagnostic reports, and hospital invoices. Proper documentation is crucial for claim approval.

  • Not Reading Policy Terms: Do not overlook reading and understanding your insurance policy. Be aware of coverage limits, deductibles, co-payments, exclusions, and waiting periods to prevent misunderstandings during claims.

  • Out-of-Network Providers: Whenever possible, avoid seeking medical treatment from healthcare providers or facilities outside your insurer's network. Using out-of-network services may lead to higher out-of-pocket expenses and more complex claims.

  • Ignoring Pre-Authorization: f your policy requires pre-authorization for specific treatments or hospitalizations, do not ignore this step. Failing to obtain pre-authorization can result in claim denials.

  • Non-Disclosure: Avoid withholding or providing false information about your medical history or conditions when applying for insurance. Full disclosure is crucial to avoid future claim disputes.

  • Late Claim Submission: Respect the submission deadlines outlined in your policy. Submit claims on time to prevent potential rejections due to missed deadlines.

  • Filing Multiple Claims for the Same Expense: Do not submit the same medical expense for reimbursement to multiple insurers if you have multiple policies. Double-dipping can lead to disputes and legal complications.

  • Non-Payment of Premiums: Ensure that your insurance premiums are paid on time. A lapsed policy due to non-payment can result in claim rejections.

  • Ignoring Exclusions: Be aware of policy exclusions and limitations. Avoid filing claims for treatments or expenses explicitly excluded in your policy, as they will likely be denied.

  • Inadequate Communication: Ensure effective communication with your insurer. Keep records of all interactions and maintain open lines of communication during the claims process. Respond promptly to any requests for information or documents.

  • Not Reviewing Settlement Details: Don't accept claim settlements without review. Carefully examine settlement details to ensure they align with your claimed expenses and policy terms.

  • Not Appealing Denied Claims: If a claim is denied and you believe it's valid, don't give up. Avoid failing to appeal the denial. Often, appeals can lead to successful claim resolutions.

Health Insurance Ombudsman

What is a Health Insurance Ombudsman or rather who is it?

A Health Insurance Ombudsman is an independent authority appointed by the government to assist policyholders in resolving disputes or grievances related to health insurance. They act as a mediator between policyholders and insurance companies, aiming to ensure fair treatment and swift resolution of issues.

What does a Health Insurance Ombudsman do?

Handling Complaints: Ombudsmen receive and investigate complaints from policyholders regarding health insurance-related matters. These can include claim denials, delays, disputes over coverage, or unfair treatment by insurers.

Mediation: They work to resolve disputes by mediating between the policyholder and the insurance company. This involves facilitating communication, negotiation, and finding mutually agreeable solutions.

Advisory Role: Ombudsmen provide guidance to policyholders about their rights and responsibilities under their health insurance policies. They also help policyholders understand the terms and conditions of their policies.

Transparency: The Ombudsman promotes transparency in insurance operations. They ensure that insurers adhere to the regulatory framework and follow fair practices while dealing with policyholders.

Recommendations: In cases where disputes cannot be resolved through mediation, the ombudsman can make recommendations for resolving the issue. These recommendations are not legally binding but are often followed by insurers.

Timely Resolution: The primary goal is to achieve timely and amicable resolutions, saving both the policyholder and the insurance company time and legal expenses.

When to Approach a Health Insurance Ombudsman?

You can approach a Health Insurance Ombudsman when you encounter issues like:

  • Claim rejections or delays.

  • Disagreements over policy coverage or terms.

  • Unfair treatment by the insurance company.

  • Non-responsive or unsatisfactory communication from the insurer.

  • Any other unresolved concerns related to your health insurance policy.

How to Contact a Health Insurance Ombudsman?

Contact details for the ombudsman are typically available on the official website of the Insurance Regulatory and Development Authority of India (IRDAI) or your country's relevant regulatory authority. You can file a complaint with the ombudsman through an online portal or by submitting a physical complaint form.

Do's and Don'ts While Filing Health Insurance Claim

Do's:

  • Read Your Policy Thoroughly: Before filing a claim, review your insurance policy to understand coverage, exclusions, and the claims process.

  • Notify Your Insurer Promptly: Report any planned treatments or emergencies to your insurer as soon as possible, respecting the notification requirements in your policy.

  • Keep Detailed Records: Maintain organized records of medical bills, prescriptions, test reports, and communications with your insurer throughout the claims process.

  • Fill Out Claim Forms Accurately: Ensure all information on the claim form is complete and correct, avoiding errors or omissions.

  • Submit Claims Timely: Adhere to submission deadlines specified in your policy to prevent claim rejections due to missed timelines.

  • Seek Pre-Authorization When Required: If your policy mandates pre-authorization for specific treatments or hospitalizations, obtain it to avoid claim denials.

  • Engage in Open Communication: Maintain clear and timely communication with your insurer. Inquire about the status of your claim and provide the requested information promptly.

  • Review Settlement Details: Carefully examine the claim settlement details provided by your insurer to verify accuracy and compliance with your claimed expenses and policy terms.

Don'ts: 

  • Delay Notification: Avoid procrastinating in notifying your insurer about planned treatments or emergencies, as this may lead to issues with claim processing.

  • Incomplete or Incorrect Information: Don't provide incomplete or inaccurate details on the claim form, as this can result in claim rejections or delays.

  • Ignore Policy Terms: Don't overlook the terms and conditions of your insurance policy, including exclusions and limitations. Be aware of what's covered and what's not.

  • Bypass Pre-Authorization: If your policy requires pre-authorization for certain treatments, don't skip this step, as it may lead to claim denials.

  • Miss Submission Deadlines: Avoid missing claim submission deadlines specified in your policy, as insurers typically have strict timelines for filing claims.

  • Double-Dip Claims: Don't submit the same medical expense for reimbursement to multiple insurers if you have multiple policies. This can lead to disputes and legal complications.

  • Assume Claim Denials Are Final: If your claim is denied and you believe it's valid, don't assume it's the final decision. Appeals often lead to successful claim resolutions.

Things to keep in mind when dealing with health insurance claims:

  • Emergency Helpline: Familiarize yourself with your insurer's emergency helpline number. It can be invaluable in critical situations, providing guidance on seeking immediate medical help and initiating the claims process.

  • Consult Your Doctor: Discuss your treatment plan with your healthcare provider before filing a claim. They can advise on which procedures or services are medically necessary and how to align them with your policy.

  • Review the Network: Periodically check if the healthcare providers you frequently visit are still in your insurer's network. Changes can occur, and staying informed helps prevent unexpected expenses.

  • Keep Claim Records: Make copies of all claim-related documents, including emails and letters to and from your insurer. This documentation can serve as evidence in case of disputes.

  • Understand Exclusions: Be aware of specific exclusions in your policy, especially those related to pre-existing conditions, waiting periods, or non-covered treatments. Understanding these can prevent claim denials.

  • Opt for Direct Billing: Whenever possible, choose healthcare facilities that offer direct billing to your insurer. This simplifies the cashless claim process and reduces paperwork.

  • Renew Your Policy Timely: Ensure you renew your policy on time to maintain continuous coverage. A gap in coverage can result in denied claims for treatments during the gap period.

  • Seek Authorization: When directed by your insurer, obtain pre-authorization for planned treatments or hospitalizations. This ensures smoother claim processing.

  • Appeal When Needed: Don't hesitate to appeal a denied claim if you believe it's valid. Insurers can sometimes reconsider claims based on additional information or clarification.

  • Review Claim Settlements: Carefully scrutinize the claim settlement statement provided by your insurer. Ensure it aligns with your claimed expenses and policy terms, and question any discrepancies.

  • Utilize Customer Service: If you have questions or concerns, reach out to your insurer's customer service. They can provide clarification on policy details and guide you through the claims process.

  • Understand Sub-limits: Some policies have sub-limits for specific medical services. Know these limits to avoid surprises when claims are settled. This is unique to every insurance provider.

Online Health Insurance

Nowadays, it has become extremely easy to purchase, review, renew, compare, and educate yourself regarding health insurance. All this can be done through your smartphone within minutes. Make an informed choice while purchasing the policy and follow the claim settlement process of your insurer for trouble-free claim settlement.

Disclaimer: *Except for exclusions like maternity benefits, undisclosed diseases, etc. Please check policy wordings for more details.
**The content on this page is generic and shared only for informational and explanatory purposes. It is based on industry experience and several secondary sources on the internet; and is subject to changes. Please go through the applicable policy wordings for updated ACKO-centric content and before making any insurance-related decisions.

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