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How to Make Health Insurance Claims During Medical Emergencies?

Team AckoJan 20, 2025

You buy a health insurance plan in hopes of getting your medical expenses covered when the need arises. Thankfully, the claim process is pretty simple and if you have the right documents in place, you can get it processed quite smoothly. Take a look at this article to know how you can make a medical insurance claim and be prepared to do so in the case of an emergency.

Contents

What are Health Insurance Claims?
Factors to Consider When Applying for a Health Insurance Claim
Making a Cashless Health Insurance Claim
Making a Reimbursement Health Insurance Claim
- Documents needed for Health Insurance Claims
Tips to Avoid Health Insurance Claim Rejections
Frequently Asked Questions
Protect Your Future with Life Insurance

What are Health Insurance Claims?

A health insurance claim is a formal request sent to your provider asking them to cover costs for a medical service, treatment, or medication you paid out-of-pocket. Claims get filed after care is received. Key details like service dates, provider names, costs billed, and diagnosis codes must be accurately documented. You submit supporting paperwork like receipts and bills so the insurer can validate the claim before reimbursing approved amounts under policy terms.

Submitting claims is less common for families with cashless plans, which allow network visits without paying upfront through direct provider settlements. However, having an online portal to view documents required, download e-cards, and check the status by policy number is extremely helpful.

Factors to Consider When Applying for a Health Insurance Claim

Know Claim Filing Timelines

Most insurers require claims to be submitted within a set timeframe. Such as within 60 days, 90 days, or 180 days of treatment or service date. If you miss the submitting window, reimbursement may no longer be valid. So, always aim to file as soon as possible after paying for a covered care expense for smooth claiming.

Collect and Check Required Documents

Insurers need adequately documented proof of your care visit and expenses to approve claims. Have the itemized bill, referral if needed, prescriptions, lab/test orders, provider authority licenses, and original paid receipts available. Double check all dates, costs billed, medication names, diagnosis codes and other key details match perfectly across these as inaccuracies can delay processing.

Understand Policy Inclusions/Exclusions

Be well-versed on what healthcare services, treatments, tests and products your policy covers and specifically excludes from coverage with limitations or conditions attached to approvals. For substantial claims, you may want to call your insurer while obtaining care to confirm your interpretation of policy terms as a safeguard instead of assuming approval.

Select Direct-to-Provider Payment if Available

If your policy and network providers allow direct claim settlement between your insurer and care facility, select this option to assign payment automatically to the provider. This approach helps you avoid personal payment and reimbursement hassles. Though additional approval coordination may still be necessary, leveraging this route when available takes work off your plate.

Making a Cashless Health Insurance Claim

As we all know, there are two types of health insurance claims – cashless and reimbursement. Let us first understand the procedures involved in a cashless claim:

Inform the hospital

Inform the billing desk about the cashless mediclaim insurance policy that you have. If you have a planned hospitalization, it would help you to inform them even before the admission takes place. But since that won’t happen in an emergency, a relative or friend should inform the hospital on your behalf, if you are admitted. If you accompany a family member who is also covered in the plan, do the job yourself.

Third Party Administrator card

You will be given a TPA card when you buy the cashless medical insurance cover. Present this card to the hospital billing desk or the TPA counter as soon as you locate it. It is always advisable for you to keep the card with you. So, if you get involved in an accident or need medical attention due to some other emergency, the card will be with either you or a friend can present it to the hospital.

Inform the insurer

You must inform the insurance provider about your hospitalization at the earliest. They will coordinate with the hospital and the TPA and arrange for the cashless claim to be paid out.

Know the network hospitals

It is always a good idea for you to be in the know about the network hospitals. This is important as cashless mediclaim insurance claims can only be availed in a network hospital. If you need to get admitted in an emergency, try your best to go to a network hospital.

Making a Reimbursement Health Insurance Claim

The reimbursement claim works in this way:

You get admitted to any hospital, whether it is a network hospital or not.
You get admitted and get treated if there is a medical emergency.
You pay the bill yourself and get discharged.
You send the bill and the needed documents to your insurance provider who then reimburses the amount, after adjusting the deductible. If there is a critical illness insurance cover associated with your plan, you can make a claim for that too in a similar fashion.

Also, read: 8 Tips to Save Hospitalization Bills with Health Insurance Policy

Documents needed for Health Insurance Claims

You need the following documents for a medical insurance claim:

Duly filled claim settlement form
Medical certificates, attested by the consulting doctors
Summary of the discharge
Copies of doctors’ prescriptions
Original pharmacy bills
Original bills of the hospital and pharmacy
FIR copy, if any
Legal documents (in case of accidents)

Keep all the documents ready when you file your claim. This will smoothen and hasten the process and you will get your health insurance claim easily.

Tips to Avoid Health Insurance Claim Rejections

Here are tips to avoid health insurance claim rejections explained in a friendly human tone:

Choose In-Network Providers

Sticking to care providers in your insurer's approved network is the right way to prevent claim denials. Out-of-network doctors often get labelled as ineligible for coverage reimbursement once a claim reaches the insurer. Search your plan's online directory before every visit.

Check Plan Documents Thoroughly

Many claim rejections tie back to misunderstandings over what services or treatments your selected plan actually covers, especially with limitations around pre-approvals. Carefully study policy terms to confirm what requires authorisation and what gets excluded from coverage. Insurers provide detailed listings.

Maintain Detailed Treatment Records

Incomplete medical charts, bills missing itemisation, illegible receipts - documentation errors easily trigger claim investigations or denials. Make sure your providers supply clearly organised records showing treatment specifics like diagnosis codes, lab orders, medication names and dosages.

Watch Claim Filing Timelines

Even valid claims will only be accepted if submitted to your health insurance provider within the designated filing window - often 30 to 180 days from treatment. Mark calendars for deadline reminders and send forms in as soon as possible after paying for covered medical expenses.

In conclusion

To ensure you get your claim, you first have to be honest and discreet when you apply for your health insurance plan. Never lie on your claim form and be open about your pre-existing illnesses, past health records, etc. If needed, opt for a critical illness insurance cover and stay protected in a comprehensive manner. Submit the correct documents and your claim will surely be processed without too many issues whatsoever.

Frequently Asked Questions

Here are some Frequently Asked Questions related to health insurance claim

How do I file a health insurance claim?

To file a claim, you must gather and submit all relevant documents, such as itemized bills, prescriptions, and any receipts showing your payment. Make sure every detail matches across your documents to avoid delays.

Can I file a claim for services received outside of my insurance network?

Yes, you can file a reimbursement claim for services received outside your network. However, sticking to in-network providers usually makes the process smoother and may prevent claim denials.

What documents do I need for a health insurance claim?

For a claim, you'll need a filled-out claim form, medical certificates, discharge summary, prescriptions, original pharmacy and hospital bills, and, if applicable, an FIR copy or legal documents in case of accidents.

How quickly should I file my health insurance claim?

Insurers have specific deadlines, typically ranging from 60 to 180 days after the service date. To ensure your claim is valid, file as soon as possible within this window.

What's the difference between cashless and reimbursement claims?

Cashless claims allow you to receive medical services without paying upfront, as your insurer settles the bill directly with the provider. With reimbursement claims, you pay first and then submit a claim to get reimbursed by your insurance company.

How do I make a cashless health insurance claim?

Inform the hospital about your cashless policy, present your TPA card at the billing desk, and ensure the insurance provider is notified of your hospitalization to coordinate the claim.

What should I do if my health insurance claim is rejected?

Review the reason for rejection, which often stems from documentation errors or misunderstandings about coverage. Address the issue and resubmit your claim with any necessary corrections or additional information.

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Disclaimer: This content is for informational purposes only and is based on industry experience and secondary sources. It is not a substitute for professional advice. Please consult a qualified expert for health or insurance-related decisions. Content is subject to change. Refer to current policy wordings for specific ACKO details.

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