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The brouhaha over withdrawal of cashless mediclaim in some hospitals by four public sector general insurers has forced many policyholders to opt for making reimbursement claims for expenses incurred during their hospitalisation. While it is certainly not comparable to the convenience that the cashless facility offers, the insured can, by following the requisite procedure laid out by the insurance company, ensure that it does not turn out to be a tedious procedure.

Here's the gist of the procedure typically followed by insurance companies or the third-party administrators associated with them and points you need to bear in mind while filing the claim for reimbursement. Upon discharge, you need to collect the bills, discharge summary and other relevant documents from the hospital. Documentation should also include diagnostic reports and medical advice, if any, from the doctor pertaining to the post-hospitalisation period and cash receipts, if any.

Make sure you verify the completed bill before signing the same. Any discrepancy (or inflated amount) would not only mean lower sum insured available for the rest of the year, but could also act as a roadblock in the path of claims processing. Once you are out of the hospital, you have to submit all the original documents related to your treatment to the insurer (if claims processing is done in-house) or to the designated TPA (third party administrator). It is advisable to collect all the documents and submit the same at one go rather than furnishing them when the TPA or the insurer's claims cell specifically asks for the same once the claims process commences. This will help eliminate any delay in claims processing.

Apart from documents from the hospital, if you have incurred any costs prior to, and after, the hospitalisation period, you need to submit these documents too, provided they are related to the cause of hospitalisation. The norm in the industry is that expenses pertaining to 30 days prior to hospitalisation and 60 days post discharge are to be reimbursed by the insurer. It also makes sense to acquaint yourself with the exclusions and sub-limits in the policy while claiming a reimbursement to avoid surprises later.

Pregnancy is not covered under several individual mediclaim policies. Similarly, treatment for cataract and piles may not be covered in the first year. Dental treatment and outpatient department expenses are admissible only under a handful of policies. Any tonics, vitamins or equipment like a pacemaker or a wheel-chair, too, could be excluded by some insurers from the scope of coverage. Once the documents are submitted, the TPA or the insurer's in-house cell will review the same and arrive at a decision on settling the claim as well as the extent to which the expenses can be reimbursed. Typically, within a maximum of 21 days from the date of submission of relevant documents, the insurance company reimburses the amount. In case the processing unit has a query or rejects the claim, an intimation letter is sent to the policyholder.

Source: The Economic Times