MEDICLAIM Reimbursement

Health Insurance (Mediclaim) Reimbursement

How to file your Mediclaim reiumbursement claim to get back your health insurance claim from the Insurance Company fast and with minimum deductions ? Here is your checklist:

What do you need to check before Hospital admission ?

1. Check the Dates in the Policy

Make sure that the Mediclaim policy is a valid policy. Please check the start and the end date. Your hospital admission should be within the valid period. The Insurance Company reimburses expenses incurred one month before surgery, hospitalisation expenses and post hospitalisation expenses incurred upto two months after surgery.

Example: You were admitted for hernia operation on 29^th June 2018. The Insurance company will pay expenses from 30^th May to 30^th July

2. Is the illness covered by the policy?

There is a waiting period before certain surgeries are allowed for mediclaim . For example a surgery for hernia is usually allowed only after the 1st year or second year. There is also a waiting period for “ pre existing illness”. If you had a hernia at the time of making a new policy, then it will be excluded for anything between 3 – 4 years before a claim is allowed. The exact waiting period is mentioned in your policy.

How does the Insurance company determine how long you had a illness ? They usually go by the notes in the Doctors prescription. If you had a note scribbled in your prescription “ swelling in the abdomen for 4 years “ the Insurance company interprets such notes as the duration of the prexisting disease. This is one of the commonest areas of dispute of a mediclaim.

Injury is excluded from the waiting period . If you had a injury to your eye and got a cataract then it will be allowed before the two or one year waiting period for cataract surgery . Many Insured try to unfairly pass off chronic conditions saying it was triggered by injury.

3. The advice for admission

This is very important. The doctor advises a hospital admission mentioning the disease . There is a note on what he plans to do. Make sure your name is correctly spelled in the advice . Some prescriptions carry a date of birth or age. Make sure that it is correctly mentioned. Some admission advice have a brief clinical note . Please check with your Doctor that it does not fall in the exclusion list.

4. Inform your TPA

Inform the Third Party Agent (TPA) before hospital admission. You may just inform your Insurance Agent, get into the internet site of your TPA and register your intimation or simply send an email to your TPA. You will find the contact details of the TPA in the health insurance ID card. Generally the following details need to be sent (a) name of hospital (b) name of doctor (c) for what treatment (d) approximate estimated hospital expenses. Please preserve a copy of the email or the acknowledgment receipt. You will need to submit it with your claim

5. Filling in the Hospital Admission Form

Please make sure that the name and addresses are correctly spellt as in the insurance ID card. Please preserve the admission letter. Please make sure that the Hospital is a registered hospital. It helps if the hospital is a “Network Hospital” i.e. they have an agreement with your TPA and then it will have a “ROHINI ID” . ROHINI stands for “ Registry of Hospitals in Network of Insurance created by the Insurance Information Bureau (IIB) . However, as per rules any Hospital which is registered with the Local authority is fit for reimbursement.

6. Preserve prescriptions and receipts

Please Preserve all the prescriptions and receipts of the treatment before surgery. They will be part of the claim. Especially if there is an expensive investigation done before admission to the Hospital please take special care to preserve it along with the accompanying prescription of doctor where he asks for that test.

7. How long to stay in the Hospital ?

Generally you need to stay in the hospital for minimum 24 hours. But there is a long list of procedures where a “ day care” treatment is allowed and patients need to stay in the hospital for a shorter duration. Most eye surgeries, radiotherapy, chemotherapy are such examples where will get the claim even if the patient stays for less than 24 hours .

Checklist for things to do during hospitalisation.

8. Which room to select

Your policy spells out the limit of your room rent. It is usually one percent of your sum insured. If you have policy for Rs 2 lakhs, then you will be entitiled to a room rent of upto Rs 2000. If you exceed the limit then other charges including doctors fees and operation theater charges are propotionately reduced from your claim . Recent policies even have an extra premium to waiver this clause !!!

9. Hospital Discharge Certificate

This is perhaps the most important document in the entire claim process. Please ensure that name, age, diagnosis, registration number of the treating doctor and a brief note of clinical management are correctly entered.

The identification sticker of any implant used needs to be stuck to the discharge summary. Eg in case of knee replacement surgery, the identification sticker of knee implant needs to be put in the discharge summary.

Please check that the medicines to take and the tests to do after discharge are correctly mentioned because they will be paid for by the Insurance company under “post hospitalisation expenses”. Eg “Come back for a review with your doctor after 10 days with an Ultrasound (USG) of abdomen.”

10. Hospital Bill and Payment

Please make sure that all the details are clearly mentioned. Usually Consultant Doctors charges are included with the Hospital bill. Some Doctors require to be paid separately. A few Insurance Company insist on including Consultant Doctors charges with the hospital bill. In that case if you pay the Doctor separately, your payment might be disallowed by the Insurance Company. Others might have fine print in the policy eg docors fees exceeding Rs Ten Thousand has to be paid by cheque and a numbered receipt has to be obtained.

11. Please submit your claim for Hospitalisation and Prehospitalisation expenses in time

You generally need to submit the claim form for hospitalisation and pre hospitalisation expenses within 15 days of discharge from hospital. The Insurance Regulatory and Developement Agency (IRDA) allows flexibility. In case you are late in submitting your claim, you need to give a valid reason eg “ I was so ill for the first two weeks after discharge that I could not submit the claim form in time “

12. Please check the correct form for filing your claim

The IRDA has a standardised claim form for hospitalisation and pre hospitalisation expense reimbursement. Insurance company sites also have the IRDA forms with their own logos. Some new forms might ask for Aadhar and PAN card which was not there in the old IRDA form. Your Insurance agent or the Insurance company website will help. Generally the IRDA form with all documents including Aadhar and PAN is ok.

13. Separate the expenses of Bed chgarges, Doctors fees and Medicines while filling the form

Since most health insurance policies have separate limit for Doctors fees, bed charges and medicines you need to separate your hospitalisation expenses under separate heads.

14. Submit originals but please keep a photocopy

The Insurance company requires all original documents eg discharge certificate, investigations etc to be submitted to the TPA for claim processing. Please keep a photocopy for your doctor to proceed with your treatment. Your agent may submit the claim papers for you. If you submit it yourself then please insist on a signed receipt mentioning which documents have been received. There are plenty of disputes on health insurance claim when originals are lost and no one knows who lost it.

15. Please include a cancelled cheque

Since the payment of claim will be by NEFT transfer through bank, you need to submit a cancelled cheque of the Bank Account where you want the money to credited

16. Check list of documents along with your medicalim reimbursement claim form

(1) Policy Document (2) Aadhar Card (3) PAN card (4) TPA Id card (5) Doctors Advice for admission (6) Original Investigation reports eg Blood , ECG etc (7) Hospital Discharge Certificate (8) Hospital Payment receipt (9) Doctors receipt if the Consultants’ charge is paid separately to the Doctor.

17. Check the TPA claim webpage on the progress of your claim

You can check the status of your claim by visiting the website of your TPA. You generally need to fill in the policy number and the TPA ID card number to access your claim details online. In case the TPA expects a clarification of additional documents, then it will be mentioned in the claims status page of your TPA

18. Understand your deductions

If your claim is not paid fully , the TPA will mention the deductions. There are a host of policy conditions where some part of your claim is deducted under “expenses generally not allowed” as mentioned in your Insurance policy. You could have exhausted part of your Sum Insured in your earlier claim in the same policy year so that the remaining was not enough to cover your present claim . You could have exceeded the sublimits of your room charge and everything else was propotionately deducted. You need to understand the deduction before complaining. However, unfair deductions by your TPA is not uncommon.

19. If you are not satisfied with your claim settlement, your can complain to your Insurance Branch office.

The TPA is not authorized to settle or reject your claim but only act on behalf of your Insurance company and inform you of the deductions which they make. If you feel your claim is unfairly , settled either partially or totally , then you can next complain to your Insurance Branch Office. You will find the address in your Insurance policy. There is a well defined and clear cut system of complaint management and even if they take time , the complaints are addressed.

20. Claim your post hospitalisation expenses

Some diseases have an expensive post hospitalisation treatment. For example in case of cancer surgery, the radiotherapy is done a month later . Such expenses will be covered under post hospitalisation expenses. It is generally for anything between 60 days to 180 days post Hospitalisation. Please check your policy about how long does the Insurance company cover the post hospitalisation expenses from the date of hospital discharge. The claim needs to filed and followed in the same way as post hospitalisation expenses.

Here is an extensive list of all documents you might need for your reimbursement claim

NO MATTER HOW MUCH YOU INSURE YOURSELF FOR, HOPE THAT YOU WILL NEVER NEED TO CLAIM YOUR MEDICLIAM POLICY !!!!