Insurance policies are not easy to understand and the difficulty magnifies even further when you are faced with a medical contingency and you have to file a health insurance claim. Whether your policy is cashless or reimbursement you don’t want a rejection due to missing documents, inadequate information or discrepancies in the claim form. To help you sail through the claim process and to ensure that you get the maximum payout, it is very important to understand how the entire claim process works. 

There are two ways to claim health insurance
  1. Cashless
  2. Reimbursement

What is a Cashless Claim?

A cashless claim is when the policyholder does not have to pay the hospital bill out of his own pocket for any medical treatment taken or surgery performed at a network hospital. The entire bill is cleared directly by the insurance company in accordance with the terms and conditions of the policy. A cashless claim can be filed for both emergency medical contingencies and planned hospitalisation.

The policyholder needs to follow these 4 steps for claiming cashless health insurance

Things to Keep in Mind for Cashless Medical Claims

Avoid claim rejection by checking your eligibility before you file a claim! Consult CMS  to know if your treatment is covered, what the co-pay is, and know if there are any deductibles or exclusions. Be prepared in advance and avoid costly mistakes.

Have you gathered all the documents required to file a claim? Are they in the right order? A single discrepancy or a missing document can get your claim rejected. Consult a CMS  expert and make no mistakes! 

If the insurance company finds any discrepancies in the medical documents during the pre-authorisation and is unable to get the required data points, then the insurance company denies the pre-authorisation. Then the insured has to pay for the treatment at the time of discharge. However, the claim can be filed via reimbursement process.

Whether your claim has been denied due to miscommunication or a missing document, consult a CMS expert and get clarity. A CMS expert will review your documents and suggest a suitable plan of action so you can claim via reimbursement smoothly and get maximum payout.

You have filed a claim of Rs 20,000 which was your hospital bill at the time of discharge. But, your insurance company approved only Rs. 8000. Did you check all the deductions in your policy? Did you receive the maximum payout on your bill? Get the settlement reviewed by a CMS expert to know that your settlement is fair.

How to Recover Deduction in a Cashless Claim?

Deductions are applied due to co-pay, proportionate, sub-limits, exclusions, and non-medical expenses. The insured can claim every medical expense except the cost of non-medical items from the policy. And, if the sum insured is exhausted on the first policy, then the rest can be claimed from the second or third policy.

What is the Reimbursement Claim?

The reimbursement claim can be filed when the insured opts for treatment at a non-empanelled hospital. Since the cashless facility is not available at a non-network hospital, the insured has to pay for the hospitalisation and medical treatments out of his own pocket and then claim reimbursement. Since a reimbursement claim is filed after the discharge process, the insured needs to provide all the required medical documents in original to the insurance company. The company will then assess the documents against the policy terms and make the payment to the insured.

Which Scenarios are Applicable for Reimbursement Claims?

The insured can raise a reimbursement claim in the following situations:

  • When the patient is admitted to a non-network hospital
  • When the insured opts-out of cashless at a network hospital
  • When the cashless benefit is rejected
  • To raise a claim for pre and post hospitalisation including emergency charges
  • For hospitalisation expenses like blood bank, radiology investigation, etc, for which the payment is made outside the hospital
  • For claiming the deduction in the second or third health insurance policy
  • For claiming Hospital -cash and health check-up benefits

The Steps Involved in a Reimbursement Claim

The insured needs to intimate the insurance company even if he/she is going to file a reimbursement claim after discharge. If the hospitalisation is pre-planned then the policyholder needs to inform the insurance company at least 3 to 4 days in advance and in case of an emergency at least within 24 hours of admission. You can send the intimation via email, call them, visit their website or call their executive.

The policyholder must collect all the original medical documents and itemized bills and submit them to the insurance company in the order mentioned in the insurance policy. These documents include –

• Copy of Gov. Id Proof with Insurance card
• Original Hospital Discharge Summary
• Original Itemized Bills
• Hospital Bill & Breakup
• Original Investigation Reports
• Original Pharmacy Bills
• Original Prescriptions
• Copy of FIR/Medico-Legal Certificate (only in case of accidental injury)
• Original Cancelled Cheque

The insured must make sure that all the documents are collected and arranged in the right order by having a SureClaim expert verify them. This is because, unlike the cashless process, the reimbursement process starts after the treatment has been completed. So the insurance company suspects an element of moral hazard and oversees every minute detail.

The policyholder has the option to fill the reimbursement claim form online or by hand or they can take the advice of a CMS expert and make sure there are no errors in the claim.

The reimbursement claim must include all the required documents. So if you have any confusion before filing a reimbursement claim, consulting a CMS expert will ensure that you have complete guidance at every step and you get the maximum payout faster.

A reimbursement claim can be tracked online from the website of the insurance company or by giving a call to the insurance company’s TPA on their toll-free number. And, if a query is raised by the insurance company while the claim is being assessed then the policy holder needs to resolve the query in a timely manner.

The policyholder can consult a claim expert for any assistance or advice on resolving a query that the insurance company has raised. CMS has assisted more than 35k users and helped them maximize their claim amount. A CMS expert will do all the legwork for you and improve the chances of maximizing your claim by 45%.

Once all the documents are verified according to the terms of the policy and the queries are resolved in a timely manner, the insurance company approves the reimbursement claim and pays the policyholder.

Things to Keep in Mind for Reimbursement Claims

  1. Check your eligibility
    It is very important to check if you are eligible to file a claim if you don’t want a rejection in the end. The insured needs to verify if:
    • The policy is active
    • The policy covers the diagnosis, procedure or medical treatment taken
    • There are any limitations or exclusions in the policy

    Confirming the coverage facilities will save you a lot of stress and surprises. Or you consult a CMS expert to know your choices as per your eligibility and saving big on your out of pocket expenses while avoiding delays and rejections.

  2. Documents to collect from the hospital
    Do not forget to collect all the medical documents, test reports, consultations and bills from the hospital at the discharge as you will need to submit all these documents in original to your insurance service provider when you claim reimbursement.

    But before you submit your claim form, make sure you have your documents verified by a CMS expert to ensure you are not missing out on any piece of information or document as it can delay your claim process or result in a rejection.

  3. Timely claim and query submission
    If the insurance company raises a query, they will give you 3 reminders to resolve the query. If you fail to resolve the query in a timely manner, your reimbursement claim can be rejected.
  4. Reimbursement denial
    You can contest a reimbursement denial and still get the maximum payout with CMS’s expert guidance. To know the reasons that can lead to reimbursement denial.
  5. Deduction in reimbursement claim
    Deductions are applied to cap the liability of the insurance company on the claim amount. This means that the policyholder has to share the cost from the bill and pay the hospital for the deductibles mentioned in the policy contract. But calculating the deductibles by referring to the policy documents is a tricky process.

    We have the expertise and experience to handle your hassles and ensure that you are completely aware of the deductions and don’t get any surprises at the last minute.