Health Insurance Claim Settlement Process

17-08-2015 / admin / 0

Health Insurance Claim Settlement Process: One of the most annoying and irritating process people usually frown upon. But since lack of knowledge and incomplete information pertaining to clear claim settlement process, people make mistakes and get into trouble. Oppositely, it’s a simple process if one can understand thoroughly and wisely act upon. Let’s get educated about this process.
Insurance company always has an obligation to settle the claims promptly. Generally, insurer appoints or hires a Third Party Administrator (TPA) for claim settlement process. TPA receives the complete details from the insurer once the policy is sold. TPA acts as a Mediator between the insurer and insured. 
There are two ways to settle the claim 
2) Reimbursement

1) Cashless Claim:

As far as health insurance claim settlement is concerned, you should always think of the network hospitals given by insurer. It is called as Preferred Provider Network. This way you can ask for cashless treatment, being eligible for this facility. There are two types of hospitalization, pre-planned or emergent. In pre-planned hospitalization, TPA should be informed pertaining to the hospitalization by filling up pre-authorization form to avail the cashless treatment in stipulated time. It is required that insured should submit the form and inform 48 hours prior to pre-planned hospitalization and 24 hours prior to emergent hospitalization. There will be minor exclusions which insured needs to pay directly at the hospital.

2) Reimbursement:

It is the settlement process where all the bills are directly settled at the hospital after getting the treatment. Insured needs to make the relevant bills and documents available for the settlement of claimed amount to the TPA. The cashless claim is the modern claim process. However, at times, even the cashless settlement may result in a reimbursement claim, depending on many factors such as miscommunication between TPA and insurer, medical expenses with a minimal amount, wrongly filled up pre-authorization form, medication through non-network hospital etc. 

Sometimes TPA has its own working style or problems due to which insured faces problems while in claim settlement. The insurer has no control over TPA. It has all the supremacy to curb insurance claims and they are not the ones who sell the policy. Considering all these, one should completely understand and study the profile and working style of TPA. You can easily gain information of these TPA through the internet, existing customers who have gone through claim settlement and hospital staff etc. These days there are insurers who don’t process through TPA and settle the claims on their own. Insured should study and keep all these things in mind while purchasing the best health insurance policy to safeguard the life of self and loved ones.


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