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Wednesday, October 13, 2010

Health Insurance Claims to get time-bound

After showing a lot of leniency, public sector insurance companies have finally decided that they will deny claims to policy holders if they fail to submit the relevant documents post discharge within the stipulated time period. This will help check fraud in the reimbursements process.

Many private insurance companies have flatly refused processing of claims if the relevant documents have not been submitted beyond the specific number of days. By doing so they have been able to control their adverse claim ratios.

Public sector insurance companies are now saying that health insurance claims have to be submitted within seven days from the discharge date. In certain cases, the insurance company will entertain claims upto 15 days from discharge date. However if the claim is beyond 15 days from the discharge from the hospital, then this has be approved by someone at the regional manager level.

Toriental Insurance company also asks its TPAs to get the papers from the policyholder within 7 days as specified in the policy and in exceptional cases, these papers can be submitted within 30 days.

New India Assurance Company has also approached the Insurance Regulatory and Development Authority (IRDA) to allow them to curtail the stipulated period for submission of claim paper from the existing 30 days to seven days.

An official from New India Assurance Company said that an internal analysis has shown that allowing an inordinately long period post hospitalization for claims to be made only benefits the fraudsters from putting in fraudulent health insurance claims. The more the time available, the more time the scamsters have to prepare fraudulent papers in support of their claims. It is difficult to carry out investigation with the hospitals for claims that come in many months after discharge.

However , one also has to note the fact that just because the patient has been discharged does not mean that he (s) has been completely cured and there might need to be significant post hospitalization claims. A balance needs to be struck in terms of fixing the timelines for your health insurance claims.

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