CLAIMS HEALTH INSURANCE

 

C  S  C     V  L  E     T R A I N I N G

 CLAIMS HEALTH INSURANCE

1.1       Health insurance claims

In health insurance, a claim is admissible when the insured person undergoes, hospitalization. This hospitalization  may be planned i.e. the patient is having a problem which is not responding to home treatment or requires an operation.

In such a case the TPA/insurance company must be informed about the sickness or treatment along with the doctor’s certificate mentioning the illness and reasons for hospitalization. This must be done before admitting to hospital. The policy number must be mentioned in the intimation letter.

Intimation is essential so that the TPA can approve Cashless facility i.e. direct payment to the hospital for the treatment and/or set the limit for payment by insurance company [In case of cashless facility].

In this chapter we look at the procedure to be followed for claims. The process for accident insurance will also be covered.

Learning Outcomes:-­‐

1.         Claim process

2.         Policy specific documents

3.         F.I.R.

4.         Death certificate & Post      Mortem certificate

5.         AML Guidelines & KYC documents

It is important to note the requirements under the policy for all claims.

CSC VLE TRAINING HEALTH INSURANCE CLAIMS

CSC VLE TRAINING           HEALTH INSURANCE CLAIMS

1.2       Personal Accident Claims

1.2.1   For PA claims the procedure is similar to health with a few differences:-­‐

On intimating the insurance company, will provide a claim form which is to be completed by the insured and by the treating doctor.

 

The accident needs to be reported to the police authorities if major injuries or death has occurred whether in public place or at home/private place.

If death has occurred, a postmortem may be required. If insurers are informed immediately they will guide the persons on the requirements. A death certificate is required. If the policy had a nomination, the nominee will be paid the claim amount; otherwise legal evidence of the title is required.

CSC VLE TRAINING  HEALTH INSURANCE CLAIMS

1.2.2   If the accident has resulted in permanent disablement the treating doctor’s certificate mentioning the disability will be required.

For      temporary      disablement  the      period of disablement and fitness certificate will be required.

1.2.3   In family personal accidental policy, in the event of death or major disablement, the policy in the name of the injured person will be cancelled. If the injured person was the insured and other family members were also covered, the insured’s name will be deleted. One of the family members must fill a fresh proposal form to designate them as the new insured.

1.2.4   If the deceased person is a parent with minor children, the details of minor children needs to be given to the insurers for consideration of the Education Fund benefit under the policy.

1.2.5   If medical expenses extension has been taken, the medical report, bills, cash memos, prescriptions etc. must also be provided to the insurers.

2.         Policy specific documents

2.1       Health Insurance: -­‐

Health Insurance claim is processed after the following documents are submitted:-­‐

Claim intimation letter: this mentions the policy number, the name of person to be hospitalized, the nature of the sickness or disease or injury and particulars of hospital.

a.         Doctor’s certificate mentioning the health problem and the need for hospitalization

b.         Claim form duly completed.

CSC VLE TRAINING  HEALTH INSURANCE CLAIMS

   

  

2.1.1   On a Cashless basis: -­‐ For a claim on cashless basis, the treatment must be only at a network hospital of the Third Party Administrator (TPA). Necessary authorizing for availing the treatment on a cashless basis as per procedures laid down is required. The procedure is provided along with policy document.

The TPA will directly collect the other original documents from the hospital:-­‐

a.         Hospital discharge card

b.         All pathological reports

c.         Hospital bills and receipts

d.         Prescriptions and cash memos

e.         Indoor case summary

f.          all consultants, specialists etc fee bills and receipts

g.         All pre and post hospitalization expenses as above must be submitted by the insured on completion of treatment or 60 days (whichever occurs first).

2.1.2   Reimbursement Claims: -­‐ In Reimbursement  Claim, following documents are required:-­‐

1.         Claim Form

2.         Discharge summary

3.         Prescription/s and cash memos for expenses

4.         All pathological Report

5.         Original Diagnosis Report

 2.2      Personal Accident

Claim intimation letter: the policy no, the nature of accident and injuries, if hospitalized or home treatment

a.         Claim    form     duly     completed-­‐     by insured and treating doctor and F.I.R.

b.         Death   claim-­‐   Post   Mortem,   Death certificate, legal heirs certificate with identification. If minor children are survivors their particulars (for education fund benefit)

c.         Other  Capital  benefit  claim-­‐  doctors certificate of nature of injury and disability

d.         Permanent Partial Disablement claims-­‐  doctors  certificate  on  nature of disability and percentage

e.         Total        Temporary        Disablement-­‐ duration of total disablement and fitness certificate for resumption of activities.

f.          Original policy for cancellation.

g.         Medical expenses extension: all medical ills, prescriptions, cash memos, receipts etc in original.

CSC VLE TRAINING HEALTH INSURANCE CLAIMS

2.3       Overseas Travel Policy

The travel documents like ticket, passport etc copies, claim form are to be submitted along with the following:-­‐

a.         For health related claim the TPA is to be contacted, the excess amount to be settled directly with the medical service provider balance paid by TPA if consent obtained. Otherwise all expenses to be borne by insured and submitted to insurer on return home. Other procedure as above for health claims

b.         For PA claims as detailed under ii) above

c.         For loss of baggage/delay of checked baggage-­‐ complaint to airline, copy for insurer

d.         For   theft   claims   or   liability   claims-­‐ Police complaint, plaint or other documentary proof including incident report

3.         First    Information    Report (F.I.R.)

This document is in the nature of a complaint made by the insured/injured party to the police. It is allotted station diary number by the police authorities and will be taken up by them for investigation.

The document contain the name, age, address of the complainant. The date and time of complaint. The date and time of loss or injury. The description of the incident. The persons(s) involved. The nature of loss. The suspects with full particulars. The witnesses, if any, to the incident.

The F.I.R. is essential for accident claims in public place or criminal incident like theft, murder etc. It must be obtained for PA claims for death and permanent disablement. It is also required for theft or liability losses.

4.         Death Certificate      &         Post    Mortem Report

The death certificate is issued by the municipal authority or local authority where the last rites are to be performed. It contains the details of the deceased person like name and parentage, age, sex, address present and permanent and nature or cause of death.

The certificate is necessary to prove a PA claim for death due to accident.

Post Mortem report is issued by the coroners department of the local medical authority where the body is sent to ascertain the cause of death. It is issued for cases where cause of death is suspicious or occurred within 48 hours of accident.

This document details the particulars of the corpse-­‐sex  and approximate age, if identified the name and other particulars; the time of receipt and conduct of the autopsy. The condition of the corpse and the various vital organs and contents of digestive system. The nature of any trauma/bleeding etc. The possible cause of death and pproximate time of death.

This document is required for PA death claim to  ascertain  the  injury  was  not  self-­‐inflicted or under the influence of intoxicants