When an insured person remains hospitalized for more than 24 hours, an insurance claim becomes admissible after getting admitted or dies in hospital after 24 hours of admission.
Health insurance is now a must because of the increasing costs of Healthcare The market for health insurance has risen dramatically since the outbreak of the Covid-19 pandemic.
The spike in Covid positive cases, hospitalizations, and deaths during the pandemic’s second phase has seen a tremendous increase. The obvious question is whether a health insurance claim is admissible if an insured individual dies in hospital.
At least 24 hours of hospitalisation is one of the basic eligibility conditions for health insurance claims. The insurance claim is only admissible when an insured person remains more than 24 hours in hospital after getting admitted or dies after 24 hours in the hospital after admission.
How to Make a Claim request when an Insured person dies in hospital?
“In the event of an insured’s death, the insurer will pay for the insured’s medical costs in accordance with the policy terms and conditions,” says the insurer T A Ramaligam, Chief Technical Officer, Bajaj Allianz General Insurance.
“Two facilities are The insurer has two options when filing Health Insurance Claims: Cashless Claims and Reimbursement Claims”, given to the insurer which he/she can opt for while filling Health Insurance Claims. When a customer selects a network hospital for medical care, the insured has the option of making cashless claims. To use the cashless facility at an empanelled hospital, the customer must display his health ID card at the Insurance/ TPA desk. The process between the hospital and the insurer is then initiated, and the customer is kept updated on the progress at each point. Nowadays, Covid-19 cases are awarded the highest priority.
Cashless Claim Process
- If hospital admission is scheduled, patients can go to the hospital’s insurance desk, which will direct them to a cashless facility. The insurance desk sends the entire case to the insurer, along with a pre-authorization application form (countersigned by the treating doctor). The cashless facility is approved by the insurer based on the case specifics and policy T&C. This approval should be granted 4-7 days prior to the treatment.
2.If you contact your insurance provider, they will remind you of any paperwork that may be needed. Following the submission of this documentation and medical information to the insurer through the insurance desk, the insurer reviews the care details in accordance with the policy terms and conditions and notifies the concerned hospital and insured.
- In addition to the documents required by the insurer, the customer must present the following documents at the network hospital:-i. A Pre-Authorisation Letter (completed by insurance desk). ii. The insurance company or Health Insurance Policy issued Identity Card. iii. Aadhar Card, Pan card / Form 60
- The original bills and treatment evidence should be left with the hospital until the treatment is completed when a patient has taken advantage of the cashless option. The hospital will exchange these bills with the insurance provider, and the insurer will process payment to the hospital accordingly.
- In the event of an unplanned or emergency medical procedure, the policyholder may simply contact the insurer via its customer service centre or chatbot to learn about the hospitals that have been empanelled. When the patient arrives at the hospital, he or she will request cashless hospitalisation by presenting the insurer’s insurance card along with a copy of the policy to the insurance desk.
- When a customer makes this application, the hospital contacts the insurance provider by submitting a pre-authorisation request form, and the insurer responds with an authorisation letter. The insurer also provides information about the customer’s insurance coverage.
- The insurer has to settle the payment of admissible claims by herself/himself once the treatment is over.
If the patient goes to a Health Policy facility that isn’t on the insurer’s list of preferred providers, the dispute is resolved on a reimbursement basis. Reimbursement claims are usually resolved within 5 days of receiving the full collection of documentation requested by the insurer. For example, Bajaj Allianz General Insurance has introduced a new feature that allows customers to send digital documents for assessment and payment instantly via the company’s self-service mobile application, ‘Caringly yours.’ Customers with health insurance will now receive their claims within 5 working days thanks to this new service.
Reimbursement Claims Process
1.The required claim forms can be downloaded from the insurance company’s website or picked up from any of the insurer’s offices/intermediaries.
- At the time of claim filing, the customer must supply the insurer with all relevant paperwork, as well as the original medical bills. A claim form, bank account details, ID cards, hospital discharge summary, investigation and diagnosis reports and bills, original hospital and pharmacy bills, as well as paid receipts and prescriptions, are examples of these records. Furthermore, in the event of an accident, a copy of the FIR has to be shared with the insurer.
3.After confirming the T&C under the contract, the insurance agent reviews the claim validity of the documents.
- Following the assessment, the insurance agency pays the recipient according to the terms of the contract.
- In the event that such mandatory documents are not received, the insurer will request these additional documents in order to make a claim decision.
- In the event of a claim repudiation, the insurer explains why the claim is not payable.