How to File a Health Insurance Claim

by Lyju Kuruvilla on  August 16, 2011 at 3:16 PM Health Insurance News
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Taking health insurance and paying premium is one story and filing for claim is another. Claiming benefits can be quiet tricky at times so you have to be smart and careful while filing for the claim. To file a Health Insurance claim with your Insurance company one has to keep the following things in mind.
 How to File a Health Insurance Claim
How to File a Health Insurance Claim

1.    Claim form duly filled and signed by the claimant.

2.    Discharge Certificate from the hospital

3.    All documents pertaining to the illness starting from the date it was first detected i.e. Doctor's consultation reports / history

4.    Bills, Receipts, Cash Memos from hospital supported by proper prescription.

5.    Receipt and diagnostic test report supported by a note from the attending medical practitioner/surgeon justifying such diagnostics.

6.    Attending doctor's certificate stating the nature of the operation performed, bill and receipt. Attending consultant's / specialist's / anesthetist's bill and receipt, and certificate regarding diagnosis.

7.    Certificate from the attending medical practitioner / surgeon that the patient is fully cured.

8.    Details of previous policies if the details are not already with TPA except in the case of accidents.

For a Planned Hospitalization:

Contact the Third-Party Administrator for your Health Insurance Policy and inform them of the planned hospitalization. Also verify the coverage terms of your policy and ensure that the Hospital / Medical Facility where you are planning to get treatment is in the Insurance company's Network. In case of a hospital that is not in the network understand the costs that will be covered. If your Insurance company offers cash-less facility then ask the TPA about the process to follow.

In case of an Unplanned Hospitalization:

Inform the TPA as soon as possible to get the Claim forms and understand the procedures for filing a claim. Keep in mind that your claim form and all supporting documents should be filed within 7 days of completion of treatment.

Once treatment is complete get all the necessary documentation from the hospital and surgeon. You will have to settle all bills out of your own pocket and get reimbursed by the Insurance Company. Check your policy to understand where pre and post-hospitalization expenses are also covered. Complete the Claim form, attach all supporting documentation and mail / fax to the TPA.

In certain cases your claim may be rejected if the treatment is not covered by your Health Insurance policy. If your claim is denied make sure you write to the Insurance company within 15 days and lodge a complaint. In case of partial payments, check with your TPA for the reasons. In most cases providing additional documentation might help recover the rest of your claim.

Source: Medindia

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