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Medical Claims: Ensure easy settlement - Money Today

23 August, 2010

The impasse between insurance companies and hospitals regarding cashless services has once again brought to the fore the troubles that plague policyholders. However, unlike the recent fracas, most problems are usually the result of policyholders ignorance, especially while making claims. Here`s how to ensure that the settlement process is smooth.

While buying a policy: The most common mistake that policyholders make is not checking for diseases that are covered under the policy. For instance, surgery for correcting eyesight, hearing aids, etc, are not insured. Some policies do not cover non-surgical charges, such as room rent or doctor`s fee. Others have a waiting period of 1-2 years for certain diseases. So scrutinise all the exclusions of a policy before buying it. While filling up the proposal form, be honest about your medical condition. Suppressing facts while taking a policy can also lead to claim rejection.

While making a claim: Ensure that you make a claim within the timeframe stipulated in your policy. Delaying the procedure may raise suspicion about its genuineness. It¿s also important to be meticulous about paperwork. Incomplete or non-submission of required documents may lead to your claim being rejected. Check that the hospital you are being treated in is included in the network of the third-party administrator (TPA) engaged by the insurance company.

Cashless claims: At times, policyholders initiate the cashless procedure after getting admitted to a hospital even though they are aware of the impending surgery. Ideally, such a request should be sent three days before hospitalisation. This ensures you have the letter of guarantee from the TPA at the time of admission. It will also clarify doubts over the claim being payable or not and, if payable, the amount that is guaranteed by the TPA. For an emergency hospitalisation, the TPA should be intimated within 24 hours of being admitted.

Always carry the health card, which has your unique membership number, along with an identity proof, to enable the TPA to provide the cashless benefit. Insist on signing the final bill before discharge and take a copy of the discharge summary from the hospital.

Reimbursement claims: Get the original discharge summary and reports from the hospital, along with the copies of all lab reports for future medical follow-ups.

Besides the claim documents, all prescriptions given by doctors for medicines and lab tests should be submitted. Ensure that receipts for all payments made to the hospital/physician are properly numbered, stamped and signed. In case of a road mishap, lodge a complaint with the police and get a copy of the FIR. To avoid problems if your claim documents are lost in transit, retain copies before submitting the originals to the insurance company.

The writer is Managing Director, Royal Sundaram Alliance Insurance Company.