How to have Smooth Claim settlement..

Abhijeet had a smile on his face, when he saw a letter from the TPA in his mail box. He had submitted his claims documents last week– all doubly checked and tallied – and was expecting his claim cheque.

To his utter shock, the TPA had rejected his ‘genuine’ claim, all because he had submitted his  health insurance documents beyond 7 days from the date of discharge.

Insurance Companies recently instructed TPAs to reject claims documents for which are submitted beyond 7 days from the date of discharge.  

 June month saw a large no. of claims so rejected due to lack of information with most agents/brokers as well as customers.

Surprised?

Don’t be! Policy terms and conditions have always required claims to be submitted within such a threshold. Insurance Companies in goodwill and as a part of customer service were waiving such a requirement, since a long time.

What does the clause specify?

Standard Policy Wordings of one of the Govt. Insurance Company’s go like this:

Intimation of Health Insurance Claim:

...mmediate notice of the claim along with other particulars such as Policy Number, I. D. Card number, Name of the Insured Member in respect of whom the claim is made, Nature of disease, Name and address of hospital/ nursing home should be given to TPA while taking treatment in the hospital, by e-mail/ fax or letter and such notice should be given within 48 hours of admission or before discharge from the hospital.

Health Insurance Document Submission:

“…final claim along with hospital receipts, original policy, cash memos, reports, claim form and other documents should be submitted to the TPA within 7 days of discharge from the hospital or nursing home…”

Which basically means you need to intimate claim within 1 day of admission and submit your claim documents within 7 days of discharge?

Is this justified?

The incessant bleeding of health insurance has forced Health Insurance Companies to enforce this clause. While Insurance Companies ofcourse have every right to enforce a policy condition, not informing customers of a crucial change of a long run practice is not the best way to do this.

How it affects you?

Instead of the 30 days window you could  submit your documents, you now have just a week – which for someone who is working even 5 days a week, is almost like submitting the documents as soon as the discharge happens.

Is there a relief?

Yes, in extreme cases of hardship if it can be proved to the satisfaction of the Insurance Company that certain circumstances made it impossible to submit the documents within 7 days of discharge, Insurance Company may provide waiver. Ofcourse, it doesn’t make sense to rely on such a relief, whatsoever.

What you need to do?

Having an efficient agent/broker who understands health and health insurance would be key in getting valid and correct claims documents to reach your TPA in time.

Call the TPA (Third Party Administrator) immediately you know about the hospitalisation schedule and within 24 hours of admission to hospital if it’s an emergency hospitalisation. You will find TPA’s number mentioned on your health insurance card and in the Policy document. Inform the TPA about the hospitalization and ask for a claim intimation number. Note down the intimation number they provide.

• Also write a mail or send a fax to the TPA or the health insurance company informing them about the hospitalization within the aforesaid time frame (this is because many health insurance companies recognize written communication only. You will also have a record of having provided the intimation.)
• The TPA or Health Insurance Company will provide you the intimation number through mail or sms but if they don’t, you must call them up and ask for the claim intimation number. This number is important for you to establish that your claim is duly intimated and is a helpful identity later in getting your claim processed and settled, so make sure you receive it.

For Health Insurance Documents Submission:

• Fill in the insurance claim form provided in the company website or available with your Agent or Broker with details like your complete name, age, gender,  date of hospitalization, date of discharge, name of the hospital/nursing home, name of the medical practitioner, etc.
• Attach all the necessary documents (mentioned in policy wordings in the Claims Notice section) with the insurance claim form and send it to the TPA or the Health insurance Company as mentioned in the policy within 7 days of from date of discharge, and get the same duly acknowledged with the time and date of receipt.

This way you can ensure that your claim is not rejected on the grounds that it was intimated/ health insurance documents were submitted later than the time limits specified.

Being proactive, reading the policy documents and complying with the time frames mentioned therein will ensure that your claim settlement is smooth and easy.

What is the Time Limit for Filing A Claim?
The time limit for intimation and submission of documents varies companies to company -