It’s been six months since Mr. Sharma, had been discharged after being hospitalized, and he is still struggling to get his claims reimbursed. It’s not that his hospitalization claim is not valid, it is the fact that each time in this time period, he has sent incomplete documents to the TPA, which has lingered the entire process and kept him waiting.
If Mr. Sharma’s example scares you, and you do not wish to be in his place while making claims, ensure you have everything ready and do not have to face rejection of your claim by the insurance company.
So what are the things you must keep in mind? Here you go:
First thing first, it is important to know your dates and not goof up, else you can end up unpaid! All reimbursement claims MUST be submitted within 30 days from the date of discharge from Hospital. This should also include all the related OPD expenses upto 30 days prior to date of Admission in Hospital. For Post-Hospitalization expenses (all related expenses upto 60 days from Date of discharge), you can submit the bills within 90 days from Date of Discharge from Hospital.
Don’t forget you need to submit original documents, hence keep them safe.
1. Discharge Card
This is a very important card that contains basic details including, date of admission and discharge, patient’s condition while getting hospitalized, brief diagnosis and treatment administered at hospital and doctor’s advice on discharge.
2. Letter of 1st Consultation and advice for hospitalization
This is the document which your doctor gives you in writing on his letterhead, mentioning if, and why you need to get hospitalized for medical treatment of a disease and if a surgery is essential. The correct date should be mentioned on the letterhead.
3. Hospital Bills with Receipts Duly Stamped and Signed
Bills and receipts are proofs on the basis of which payments will be made to you. The bill should be detailed. In case, a standard pre-printed receipt is not available and the same is furnished on a hospital letterhead, a stamp is must. Also insist that the Registration No. of the hospital is mentioned on the bill.
4. Medicine Bills with doctor’s prescriptions for the same
Each medicine bill must have a date on it and should bear the patient’s name too. Also, these bills, if accompanied by the doctor’s prescription, give authenticity to your claim.
5. Medical reports, bill receipts and doctor’s Letter for all tests performed.
All the tests that you undergo, must be advised to you by your doctor and documented by way of doctor’s letter/s. A receipt of payment should be produced and the medical report should be submitted. Also, the X-Ray films must be ready as the TPA has a right to call for X-ray films.
6. Consultation Receipts
This is the proof of payment made to the doctor in exchange of his consultation. As these payments are small in denominations, you may often forget to get these receipts. But not getting them means losing out on payments. The best thing to do is to insist on getting a receipt, each time you visit the doctor for consultation.
Besides the basic documents, some documents which are particular to certain cases and which must be carried are:
- Biometry Test Report
- IOL Sticker (Intra-Ocular Lens sticker indicates the “Make” and “Model” of the lens along with its serial no. This is a proof that cataract surgery was performed and an IOL is implanted).
- Accident Cases involving Motor Vehicle or injuries caused by other persons
- First Information Report (FIR): A copy of the report filed with the nearest police station informing them about the accident/incident. This report can be filed in any police station that is nearest to the place of accident/incident and a copy of the report is given to the complainant free of cost.
- Non-Alcohol Certificate: If the claimant is a driver in an accident case, a certificate from a doctor indicating that the driver was not under influence of alcohol while getting admitted in the hospital, is required. This can also be mentioned on the Discharge Card.
- MP Test Report: If the treatment for malaria is taken in a hospital, a test report proving that it is a case of Malaria, is a must.
- Death Certificate: This certificate is issued by the local Municipal Authority or any local authority.
- Death Summary: When the patient has been shifted out of hospital following his death, no discharge certificate is issued. However, in lieu of the discharge card, a death summary is issued indicating that the patient is no more, and also indicating the cause of death.
Once you have all the relevant and necessary documents in place, and you know the dates and deadlines within which you need to apply for a claim, the process will never get cumbersome. And although it took quite a while for Mr. Sharma to realize this, he did manage to be up-to-date with his documents, and finally got his claim passed! So, don't be another Mr. Sharma, rather be Proactive!
Note: These documents are the essential ones and on a case to case basis more documents may be called for, by the TPA for claim settlement.
