Health insurance claim settlement

Most insurance companies appoint a Third Party Administrator (TPA) for the purpose of claim settlement. This means that after buying the policy, TPA becomes your point of contact for any claim settlement. Some insurance companies have an in-house facility for claim settlement. They are called as in-house TPAs. There are two ways in which claims are settled-

• Cashless Claim: Every insurance company has a list of network hospitals i.e. hospitals with which they have a tie-up. For availing the cashless treatment, you have to, not only use the services of the network hospitals, but also, notify the TPA in advance for planned hospitalisation or within stipulated time limits for emergencies. The claim amount has to be approved by the TPA after which the hospital settles the amount with the TPA/insurer as the case maybe. There may be certain items in the expense list which may be excluded in the policy. The same will have to be settled directly with the hospital.

• Reimbursement Claim: Reimbursement facility can be availed of at both the net work and non-network hospitals. Under this, the insured settles the hospital bill and then claims the same from the insurance company. The insured has to ensure that all the relevant bills and documents are submitted to the TPA or the insurer as the case may be, in a timely manner. The claim will then be processed subject to the terms and conditions of the policy.

The claim settlement process takes a minimum of 21 days and the number of days will increase if you have not provided all the information required by the TPA in one go. You need to check the status of you claim directly with the TPA or with the agent from whom you bought the policy. In case your claim gets rejected, because the TPA is not satisfied, you can approach the Ombudsman and state the issue. Being an impartial party, you are like to get a judgement which will be acceptable. In order to avoid hassle free claim settlement, read the policy document and make sure you follow all the listed requirements.

Some health insurance policies have the co-pay feature which means a certain percentage of the expenses will have to be paid by the insured and the balance will be paid by the insurance company. The most common co-pay proportion is one in which the insured pays 20 percent of the expenses and the insurer pays 80 percent.