Understanding Health Insurance Claims And Policies

Health Insurance policy helps you in your medical crisis offering the benefit of cashless hospitalization and quality treatment If the process is duly followed it becomes easier to get claim settlement. However, many times there may be a situation when claim is denied due to non coverage of the disease under the policy and treatment not being covered by the policy. Such situations may leave you badly frustrated. So, it is always better to gather knowledge of how health insurance claims are processed, how and why are they accepted and rejected and what are the different types of health insurance claims.

Types of Health Insurance Claims

Basically there are three types of health insurance claims:
Cashless Claims
Reimbursement Claims
Pre and post hospitalization claims

a. Cashless claims: As the name suggests, cashless claims mean where the claim is settled without you paying any cash to the hospitals to avail treatment. This happens if the hospital where you are undergoing treatment is a network hospital and you have aptly followed all the procedures to avail cashless treatment.

b. Reimbursement Claims: In this type of health insurance claim the hospital bill needs to be settled by the insured as most probably the hospital in which you are availing treatment is not on the network of the insurance company. Once you settle the bills with the hospital you need to submit the documents as required by your insurance provider and file a reimbursement claim. If all the documents are duly submitted then the money spent up to your coverage extent on the treatment is reimbursed.

c. Pre and post hospitalization claims: Most of the health insurance policies provide coverage to pre-hospitalization expenses for 30 days and post hospitalization expenses for 60 days. You need to submit the original bills to claim the expenses.

Under what circumstances my claims can be rejected?
Most of the time, the claims are rejected because of improper communication between the insured and the insurance company. Always pay heed to the following before filing a claim for availed treatment:

Does my policy cover the treatment for the disease diagnosed?
Do I need to get prior approval before getting hospitalized?
Have I submitted all the required documents and prescriptions as mentioned in the policy document?
Have I timely submitted the documents or not?

What if my claim is genuine but still being rejected by the insurance provider?
You can always take a legal route if you think that your claim is wrongly rejected.