Many of us purchase health insurance for peace of mind during our tough times. But the purchase of health insurance is just the starting point. Claims have to be filed for every hospitalisation and relevant documents have to be submitted from the policyholder’s side for the mechanism to work. The insurer will then have to go through your paperwork and ultimately decide whether your claim stands or not. Claim scrutiny has been put in place to safeguard the interests of the policyholders and insurers. Here’s everything you need to know about this process.
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Claim scrutiny: What is this process, and how does it impact health insurance claims?
Claim scrutiny is the process through which the insurer or the third-party administrator (TPA) checks the validity of the claim filed by the policyholder. They have a checklist that the claim has to pass through to get approval. Claims that don’t pass this checklist are rejected, and the policyholder will have to settle with the hospital using their own money. In some cases, the documentation may not be sufficient to make the case for the policyholder. Additional documents may be requested in such cases.
Here’s how the process of claim scrutiny works. The process is applied to both cashless claims and reimbursements. The process begins once the policyholder initiates a claim for the treatment with the insurer/TPA.
The policyholder provides relevant documentation to support their claim to the insurer/TPA. Once these documents are received, they are reviewed by the stakeholders to check them for accuracy. These documents include medical bills, consultation notes, discharge summaries, and diagnostic test reports. With cashless claims, this process starts with the pre-authorisation documents. In the case of reimbursements, it starts once the claim is made post-hospitalisation.
Health insurance policies come with a set of ironclad terms and conditions and exclusions. Claim scrutiny is applied to check for compliance with the policy. This could include the need for treatment/hospitalisation, checking for waiting periods for pre-existing conditions, any sublimits that may have been crossed, and whether the disease in question has been excluded from coverage.
Claim scrutiny is also an important tool when it comes to fraud prevention. Fraud can happen in many forms when it comes to health insurance. Claims can be made for treatments/services that have not been performed. Policyholders can also misrepresent their health history and pre-existing conditions. Hospitals may overcharge for certain procedures or fabricate the need for hospitalisation to claim insurance benefits. Claim scrutiny is used to find such fraud, as they have a negative impact on the bottom line of the insurers.
Falsification/non-disclosure of information: Not disclosing pre-existing conditions and other medical details can lead to rejection of claims post-claim scrutiny.
If the claim falls within the waiting period stipulated in the health insurance plan, it will not be entertained by the insurance company.
There are certain diseases, treatments, and conditions that the insurer will not cover. If the claim is related to these exclusions, it will be rejected during scrutiny.
Documents such as a discharge summary, diagnostic reports, and medical bills form the backbone of a claim. They have to be complete and accurate for the claim to be approved.
If there is a mismatch in the data points provided by the policyholder, such as name, age, and treatment performed, the claim can be rejected.
Cashless claims from hospitals that are not empanelled with the insurer will face rejection.
The insurer will only cover treatments that are deemed to be medically necessary for the patient. Treatments that are performed for sheer convenience and have no impact on the overall health of the patient will not be approved for coverage by the insurer.
Here’s a simple checklist for policyholders to follow for a smoother claims process:
Claim scrutiny is a very extensive process. Documents are thoroughly vetted by experienced personnel, and these days, advanced technology such as AI has been introduced to keep the process fair and fast. Policyholders should also be proactive. They must ensure that they submit relevant documents in a timely manner and without hiding facts so that their claims can sail through.
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Reviewed by Dr. Harshita Dahiya 
Acko Technology & Services Private Limited
#36/5, Hustlehub One East, Somasandrapalya, 27th Main Rd, Sector 2, HSR Layout, Bengaluru, Karnataka 560102
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