Insurance Claim process
Hassele free health claim process in two way
Cashless Claim : The cashless claim facility keep you woory-free during a medical emergency as you can avail of treatment at any of the network hospital empaneled .The hospital bill directly settele.
cashless claim process
Request for pre-authorization
complete the pre-authorization from available at the hospital's inrance/TPA Desk and send through fax.
Approval letter sent by the claim management team
Hospital/Insured to respond tothe query raised by the claim management team.
Reimbursement claim : Non-network hospital for treatment, they have to bear the medical expenses from pocket. Reimburse the cost, subject to policy term and conditions, after submitting valid documents.
Reimbursement claim process
Submission of claim from along with required documents, as per the policy term & conditions
approval letter sent by the claim management team
Insured to respond to the query raised by the claim management team.
Tip to avoid claim rejection
Claims may get rejected, and this can be due to various reason.
Do not hide any information such as any pre-existing condition at the time of buying a policy.
contact the insurer as pre the time specified for planned and emergency hospitalisation.
Keep vital documents securely including medical reports and submit them when filing a claim.
List of the documents Required for Health Insurance Claim for cashless and reimbursement
Claim form duly filleed and signed
Docctor's prescription and referral letter
Diagnostic test and medical reports
Original bills, recepts, and discharge pappers from the hospitalization.
Original bills from pharmacy/chemists
Police report or FIR in case of perosonal accident
post-mortem report, if conducted
death certifficate
Test Report List
Physical examination (to be signed by the doctor with minimum MD (Medicine) qualification)
Blood sugar (fasting/post prandial),HBa1c
Lipid profile
serum creatinine
Urine routine and microscopic examination
ECG
Eye check-up
Genetics
Any other test required by the company
Prepolicy check up for whom -proposers aged 50 years
WHAT IS THIRD PARTY ADMINISTRATOR?
A TPA is an organisation that processes the insurance claims in a timely and hassle-free manner filed by both corporate and retail policyholders. The TPA works as an intermediary between you and the insurance company, and they are generally hired by the insurers to process the health insurance policy claims. These bodies are licensed by the insurance regulatory body, Insurance Regulatory and Development Authority of India (IRDAI).
Over the years, the health insurance sector has evolved tremendously, and the insurance companies today offer various plans. Also, the number of insurance plans sold in a year has increased considerably. In such a situation, many insurance companies find it challenging to track various health insurance-related operations, especially handling insurance claims. It requires a specialised workforce and expertise. Therefore, the IRDA allowed the insurers in India to hire TPAs.
The health insurance TPA was introduced in 2001, and since then they are held responsible for:
Assuring high-quality services to the policyholders filing their claim
Handle a high amount of insurance claims on behalf of the insurance companies
THE ROLE OF TPA IN HEALTH INSURANCE
The role of TPA starts immediately after the policy is issued. Some of the important function that the TPA carries out include:
Issuance of Health Card
For every policy the insurer sells, they issue a health card to the policyholders. The card validates the policy and holds vital information about the policy, including policy number and the TPA responsible for the claim process. Often, the insurance companies outsource the health card issuance process to the Third Party Administrator.
If you need hospitalisation, you must inform the insurer or the TPA about it and show this card at the time of admission. It is one of the important documents required to complete the claim process.
Health Insurance Claim Settlement Process
One of the health insurance TPA's primary responsibilities is to act as an intermediate between the insurer and the policyholder to expedite the claim settlement process. The TPA's role is to check and verify all the policyholder's documents in favour of the claim. The TPA can ask you to provide additional information (as needed) to validate your claim request. Depending on the policy terms, the settlement is done either on a cashless basis, or the insurer reimburses the amount.
Irrespective of the claim mode, the TPA will check the claim details and verify the same. For cashless claims, the TPA collects the documents from the hospital, and in case of reimbursement, they will ask you to provide the supporting papers and copies of bills and receipts.
In some cases, if the TPA suspects a wrong claim, it might take a second opinion and investigate the hospital records before approving the request.
Maintaining A Database
TPA helps the insurer to maintain a database. After the policy papers are issued to the policyholder, all the relevant documents, including the proof identity and residence proof, are transferred to the TPA for record maintenance. All policy-related communication is with the TPA and not the insurance company.
Providing Customer Support
Another critical role of health insurance TPA is providing 24x7 customer service to the policyholders. It is responsible for attending to the customers' queries and providing information about the eligibility for different plans, claim settlement process, network hospitals, claim settlement status, etc.
Better standardisation
Since the TPAs have specialised skill sets, they help the insurance companies standardise the procedures and set a meticulous process for both insurers and the insured. The TPAs help the policyholders avoid confusion regarding the various processes of the insurer. This also allows the insurers to improve the quality of services provided to their customers and avoid fake claims.
Provide value-added services
Apart from issuing health cards, maintaining documents, and guiding the policyholders through the claim settlement process, the TPA also provides value-added services like arranging ambulances for the patients, directing patients to wellness programs, providing medical supplies, etc
Treated at a non-network hospital, they will need to pay the bills out of their pocket and later apply for reimbursement. The TPA will issue an authorization letter to the hospital, which allows the hospital to track the case.
Understanding The TPA Payment Process
Once the policyholder gets discharged, the hospital will send all the bills to the TPA for payment. The TPA then sends all the relevant documents, including bills, to the insurer for processing. The TPA processes the payment to the policyholder if the claim is approved. If the claim is rejected, the TPA provides the policyholder with a reason for the rejection and steps to rectify the issue.
Understanding The TPA Dispute Resolution Process
In the event of a dispute, the TPA acts as a mediator between the policyholder and the insurance provider, ensuring that the issue is resolved amicably. The TPA investigates the issue and provides a resolution that aligns with the terms and conditions of the policy.
Policy Claim
Asking for policy-money, under the terms of an insurance policy.
- A formal Request, to an insurance company;
- Asking for a Payment;
- Based on the Terms of the Insurance Policy.
Types of policy-claims in Life insurance
Claim by Maturity : Claim may arise because of survival of the Life-Assured, up to the End of the policy-term, which is, the Date of Maturity. That happened in Endowment plan .
Claim at periodic Intervals : Survival-Benefits :Claims may arise because of survival of the life-Assured, up to specified period. That happened in Money-Back plan.
Claim by Dath : Claim may arise, due to Death of the Life-Assured, during the Term of the policy.
Maturity Claim and Survival-Benefits need Requires documents
- Original Insurance Policy Document.
- Discharge Form, Duly Stamped, signed, and witnessed. ( Discharge voucher will show the gross amount of claim)
- Proof of age, in case, the policy was issued without the Age Proof.
- Documents of Assignment (Assignment is generally done to provide security against Loan)
Death Claim need required documents
1 intimation of Death : Send an 'Intimation of death', to the branch office of the Insurance Company.
Intimation should be sent in writing , by any of the below
- The Nominee
- The Assognee of the policy.
- The Relative of the Deceased Policy Holder
- The Employer
- An Agent or the Development Officee
The Letter of intimation of Dath Contain
- Name of the Life Assured
- A statement, that the Life Assured is Dead
- The Date of Death
- The Cause of death
- The place of Death
- The Relationship of the Claimant with the Life Assured
- The policy Number
- Certificate of death, issued by the Municipal Authorities or Public Record office.
Submission of Proof of Death
- A statement by the doctor, who Last Treated the Deceased.
- A Certificate by the Hospital, where the policy holder died.
- A Certificate by the Hospital, where, the policy holder died.
- A Certificate from the Employer, where the policy holder Last worked.
- A Certificate of cremation or Burial (Early Claim)
Submission of age Proof
- Birth Certificate
- school Certificate
- Pas port
Proof of Title of the Claimant
The Nomination is subsisting at the time of death, no proof of title is needed
A Succession Certificate ( Is issued by a competent court)
A Registered will
Payment of the policy
All these formalities are completed, the insurance Company issues a Discharge form for completion , which is to be signed by the person.
Note:
According to insurance Regulatory and development Authority of India A Life Insurance has to process the death claim without delay within
Early Death Claims Required documents
Claims arising within 3 years
- Policy Document
- Discharge Voucher
- Assignment Deed
- Age Proof
- Proof of Title
- Statement by the Doctor , who Last Treated the Deceased
- Statement by the Hospital ,where the Life Assured died
- Statement from the Employer
- Certificate of cremation or Burial
Note :Certification of cremation or burial is official Legal document that serves as proof that some one did
Death due to Accident or Un-Natural death case required documents
- Post-Mortem Report
- Police Inquest Report
- Panchanama Report
- Magistrate Report or coroner verdict
- Forensic report
- Chemical Analysis report or viscera