How to File a Health Insurance Claim?

By  ,  Onlymyhealth editorial team
Jul 25, 2011

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Obtaining a health insurance and paying for its premium is one job done, but filing for its claim is another. Claiming for your advantages and related benefits can be quite troublesome at times, thus one has to extra cautious while filing for the claim.


In order to file a health insurance claim with his or her insurance company, one has to bear following things in mind:


1.    Claim form must be rightly filled by the claimant. Also make sure that your signs are accurate.


2.    Release your certificates from the hospital. One must look for all the certificates to be discharged from the hospital such as Doctor’s consultation history or reports and so on.


3.    Along with proper prescriptions, bills, cash memos and receipts must be discharged from the hospital.


4.    Stating the natures of the operation conducted or treatment performed, an attending doctor’s certificate is a must. Along with that, one must attach anesthetist's bill and receipt, and certificate regarding identification of an ailment.


5.    Except in the case of accidents, details of previously obtained policies must be given, which are not already with TPA.


Planned Hospitalization


One needs to contact the Third Party Administrator in order to inform them for the planned hospitalization. It is essential to check for the coverage terms of one’s policy and make certain that the hospital or medical facility where you plan to get treated is in the Insurance companies set of connections.


In cases, where the medical facility or the hospital is not in the insurance company’s area of network, then it is difficult for the cost to get covered. And, if your insurance company provides you with cash-less ability, then it is a must to inquire from the TPA in order to follow the due process.


Unplanned Hospitalization


It is important to update the TPA quickly in order to obtain the claim forms and to understand the measure while filing for a claim. Bear in mind that all your claims and related documents must be filed within 7 days of treatment.


One needs to get all the essential documentation, once the treatment is complete. This can be obtained from the hospital and the surgeon. One needs to settle all the bills from his or her own pocket in order to get the compensation from the insurance company. One needs to tally with their policy in order to cover both- pre hospitalization and post hospitalization expenses.


In some cases, your claim might not be passed if at all the treatment of the critical illness or disease is not supported by your health insurance policy. However, if your claim is rejected, make sure you are writing to your insurance company within a time span of 15 days, in order to lodge a complaint.


One needs to check with their TPA, in cases of partial payments. However, mostly in all the cases offering additional documents will help in recovering the left over claim.


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