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How Health Insurance Claims Get Paid

Health insurance is a complex financial product that most people in India find difficult to understand. A basic health coverage plan financially protects you (the policyholder) in case of medical emergencies and surgical treatments.

Generally, there are two types of health insurance covers available in the market.

  1. Indemnity Plans

  2. Defined Benefit Plans

When it comes to the indemnity plans, compensation is provided for the actual expenses incurred for up to the amount insured for specified illnesses (depending on the terms and conditions of your policy). Whereas, in defined benefit plans, you are insured for a pre-agreed amount for certain medical illnesses. You can utilise the sum insured only in case you contract these illnesses and provide acceptable proofs for the same.

A lot of people in India prefer seeking indemnity plans, which are also famously known as Mediclaim policy. As a matter of fact, we will be discussing in detail how insurance gets paid in an indemnity policy.

There are two ways in which indemnity health insurance claims get paid –

  1. Cashless services at the hospital

  2. Reimbursement of expenses

Cashless services at the hospital

Many insurance providers will give you a list of network hospitals when you seek insurance from them. So, in case of medical emergencies, if you are being treated in any of the listed network hospitals, you can avail cashless health insurance.

All you have to do is provide your insurance card at the hospital and continue your medical treatment without having to pay any money. The only clause that you need to fulfil is the medical condition that you are suffering from needs to be covered under your health insurance plan.

The hospital will send across all the medical expenses incurred by you to the insurer after your discharge. The insurer will evaluate the sent bills and then compensate the amount as needed.

Reimbursement of expenses

Another way in which you can claim your plan is through reimbursement. Here, you will have to pay for all the medical costs incurred by yourself while getting the treatment. After your treatment is done, you can submit the original bills to your insurer and seek compensation for the incurred expenses.

The insurer will first assess the bills submitted, and upon verification, they will reimburse the amount based on your health insurance sum assured limit. This type of claim settlement usually comes into the picture when you are seeking treatment in a non-affiliated hospital.

When Can You File A Claim?

In most cases, your health insurance plan requires you to be admitted to the hospital for at least 24 hours or more to avail the said benefits. This will be explicitly mentioned in your health plan documents, so make sure that you are going through it carefully before signing the deal.

On the other hand, it is also essential to keep track of health insurance validity. If your policy has lapsed, then you will not be able to make any claims and avail the benefits.

We understand that certain health insurance terminologies can be difficult to understand. However, you still must be well-versed with a few terms. You should know about things such as limits on specific procedures, room rent caps, waiting period for particular health conditions, co-payment, and exclusions in the policy.

Most health plans come with a waiting period for specific medical conditions. This means, if you are suffering from the said illnesses, you will not be able to claim until the waiting period is over.

How to Get Claims Paid?

All the network hospitals have an insurance desk which you will have to visit during your treatment there. To avail the cashless claim benefits, simply fill a pre-approval application at the network hospital. In case of emergencies, intimation has to be done within 24 hours of the hospitalisation. 

When seeking cashless claim, all you require is an identity proof and the health-card provided by the insurance provider. The remaining documentation will be taken care of by the third-party administrator (TPA) available in the hospital.

A Final Thought

It is highly recommended that you keep the hospital in the loop regarding your health coverage right from the beginning of the treatment. This will help avoid any future conflicts, and the hospital will inform you immediately in case you run out of coverage. Also, to make sure the claim settlement process is hassle-free, provide all the requested documents and bills.

In case you need comprehensive insurance, get in touch with us at Finserv MARKETS. With Bajaj Health Insurance, you can benefit from swift claim settlement, reinstatement benefits, customised insurance plans, extensive coverage, and so much more. 

Browse through more health insurance benefits and choose the one that is most suitable for your needs. 

So, why wait? Get insured with us today!

Also, read in detail about the health insurance tax benefits you can avail with medical plans available on Finserv MARKETS.

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