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How to ensure easy settlement

Follow correct procedures to avoid roadblocks when making medical insurance claims.

Ajay Bimbhet | Print Edition: October 17, 2010

The impasse between insurance companies and hospitals' cashless services has once again brought to the fore the troubles that plague policyholders. However, unlike the recent fracas, most problems faced by policyholders usually stem from their ignorance, especially when making claims. What steps should you take to ensure that the settlement process is smooth?

Checklist

  • Make a claim within the time stipulated in the policy
  • Ensure that the hospital is in the network of the insurance company's TPA
  • Don't suppress facts about your medical condition when buying a policy
When buying a policy: The most common mistake policyholders make is not checking for diseases covered under the policy. For instance, insurance cover does not extend to surgery for correcting eyesight and hearing aids, among other things. Some policies do not cover non-surgical charges, such as room rent or doctor's fee. Others have a waiting period of 1-2 years before treatment expenses for certain diseases can be claimed. So, scrutinise all the exclusions in a policy before buying it.

When filling up the proposal form, be honest about your medical condition. Suppressing facts while taking a policy can also lead to rejection of your claim. When making a claim: Ensure that you make a claim within the time frame stipulated in your policy.

Delaying the procedure may raise suspicion about its genuineness. Your claim may be rejected because of incomplete documentation. And importantly, check that the hospital you are being treated in is included in the network of the third-party administrator (TPA) engaged by the insurance company.

Cashless claims: At times, policyholders initiate the cashless procedure after getting admitted to a hospital even though they are aware of the impending surgery. Ideally, such a request should be sent three days before hospitalisation. This ensures you have the letter of guarantee from the TPA at the time of admission.

It will also clarify doubts over the claim being payable or not and, if payable, the amount that is guaranteed by the TPA. For an emergency hospitalisation, the TPA should be intimated within 24 hours of being admitted. Always carry the health card, which has your unique membership number, along with an identity proof, to enable the TPA to provide the cashless benefit. Insist on signing the final bill before discharge and take a copy of the discharge summary from the hospital.

Reimbursing claims: Get the original discharge summary and reports from the hospital, along with the copies of all lab reports for future medical follow-ups. You will also have to submit all prescriptions for medicine and lab tests.

Ensure that receipts for all payments made to the hospital/physician are properly numbered, stamped and signed. In case of a road mishap, lodge a complaint with the police and get a copy of the FIR. To avoid problems such as the loss of your claim documents in transit, retain copies before submitting the originals to the insurance company.

The writer is MD of Royal Sundaram Alliance Insurance Company

Courtesy: Money Today

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