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What Is an Insurance Claim?
An insurance claim is a formal demand made by the insured to the insurer seeking payment based on the terms in the policy bond. The insurer is expected to make the payment after ensuring that the claim is valid and all procedural requirements have been met.
What Is a Health Insurance Claim?
A health insurance claim is a formal request made to the insurer to settle the medical bills incurred by the insured as per the terms of the insurance contract. Once again, the insurer must review the claim to ensure its validity, and then make the required payment.
Health insurance claims can cover a variety of medical costs. Insured parties generally file claims against their medical insurance during hospitalisation, as hospital bills can prove unaffordable in the absence of insurance. But insurance plans nowadays offer a variety of permutations and combinations. Thus, depending on the policy bond in question, health insurance claims can relate to preventive medical tests, dental care, prescription medicine, and more.
How Far Does Your Claim Extend? Read Your Policy Bond
Knowing the summary of your health insurance plan is not enough. You must examine the policy bond in detail before seeking any kind of medical treatment and, most importantly, before buying the plan. The policy bond might have fine print in the form of exclusions or restrictions that you had not considered. Does your insurance plan cap the amount that you can claim per day? Is there a waiting period for your pre-existing diabetes? Will your policy cover the costs if your mother goes in for cataract surgery or are optical procedures not included? What if you require treatment at a hospital that is outside the insurer’s network? How will that affect your claim settlement?
As you can see, you cannot claim for all medical costs. Moreover, many policies nowadays require that the insured also share the risk. This is achieved through deductibles and out-of-pocket expenses like co-pay and co-insurance. Thus, even if you do have a substantial sum assured with limited exclusions and restrictions, you will still have to bear some of the costs before filing a claim.
Types of Health Insurance Claims
- Reimbursement Claim – In the case of a reimbursement claim, the insured must settle all hospital bills. At the time of discharge, he/she must collect all the required original paperwork related to the hospitalisation. This will include billing details, test reports, discharge summary, etc. These papers must be submitted to the insurer at the time of filing a claim. The insurer will then review the claim and, if it is valid, make the payment within a stipulated period.
- Cashless Claim – This type of claim is called ‘cashless’ because the insured is not required to make any payment to the hospital. The hospital collects the patient’s insurance details and forwards these to the insurer. In this case, billing matters are settled directly between insurer and hospital. However, this usually holds only if the patient seeks treatment at a hospital that is within the insurer’s network.
- Pre-hospitalisation and Post-hospitalisation Claims – Most insurance policies offer coverage for pre-hospitalisation expenses (e.g. diagnostic tests) and post-hospitalisation costs (e.g. post-operative medicines, consulting fees). Generally, these take the form of reimbursement claims—i.e. the insured submits the original bills for the same while filing the claim and the insurer settles these costs after reviewing their validity.
Third-party Administrators
Another term that shows up when discussing health insurance claims is that of third-party administrators (TPA). A TPA is a body that specialises in processing claims. They bring their specialised skills to the table, which leads to claim processing becoming cost-effective. Insurance companies often outsource all or part of their claims processing responsibilities to TPAs, although they may even set up an in-house TPA to handle this aspect of the insurance business.
That it "What Is a Health Insurance Claim?", Hopefully it can give information For you. Thanks YourInsuranceStep Update.