How to File a Claim after Hospitalisation

The recent confusion & noise over withdrawal of cashless mediclaim in some hospitals has forced several policyholders to pay from their own pockets during hospitalization and subsequently file for a cliam.

While cashless is the most convenient feature, if one follows the necessary procedures as suggested by the insurance company, he/she can ensure that the reimbursement doesn’t turn out to be a tedious task.

While filing the claim for reimbursement, the following few points need to be kept in mind.

You need to collect all the bills, discharge summary, diagnostic reports, medical advice from the doctor pertaining to the post- period, and cash receipts upon discharge. The final & complete bill needs to be verified before signing the same. Any inflation in the bills would mean lower sum insured available for the rest of the year and it could also pose as a roadblock to claims processing.

All the original documents related to the treatment have to be submitted to the insurer, if claims processing is being done inhouse or to the designated TPA once you are out of the hospital.

Never wait for the TPA or the insurer’s claim processing cell to ask you for the documents once the claims process commences. It is advisable to submit all the documents in the beginning at one go. This will eventually help remove any delay in the claims processing.

Any costs that have been incurred 30 days pre or 60 days post hospitalization will also to be reimbursed by the insurer, so any documents pertaining to the same cause have also to be submitted.

You should also acquaint yourself with the exclusions and sub-limits in the policy while claiming a reimbursement to avoid surprises later.

Treatment of piles & cataract is not covered in the first year. Pregnancy is not covered in most of the individual mediclaim policies. Dental treatment and outpatient department expenses are also not covered in most of the policies. Any tonics, vitamins or equipment like a pacemaker or a wheel-chair, too, could be excluded by some insurers from the scope of coverage.

After submission of your documents, the TPA or the insurer’s claim processing cell reviews the same & arrives at a decision on settling the claim & the extent to which the claims can be reimbursed.

The insurer reimburses the amount within 21 days from the date of the submission of all the relevant documents. Intimation letter is sent to the policyholder in case of any queries or rejection of claims. Get info on handling claims and compare insurance policies.