The claim settlement process is arguably a hectic procedure policyholder generally face. There are many things involved in claim settlement that people should understand clearly before purchasing a policy. It is always advisable to read the fine prints of your policy that underline the most important things – the eligibility criteria of the claiming process. Once you get which fields are included and excluded, the remaining steps seem very simple. Generally, two ways the claim settlement process have been done – cashless claim and reimbursement.
Unlike cashless claim, reimbursement requires you settle the amount of your treatment in the hospital and then you can claim for the expenses you spent for your medical attention. This type of settlement claim can be available for both networked and non-networked hospitals.
The insured must submit the essential documents such as treatment bills to back the claim. The TPA (Third Party Administrator) would look after your claim and compensate you accordingly.
In case of a cashless treatment, the insured has to follow certain rules and regulations as defined by the companies. The cashless treatment option is only available in the empanelled hospitals of the companies. The process is more known as the ‘Preferred Provider Network’. For the cashless settlement, insurers have two hospitalization types – pre-planned and emergent. In case of pre-planned claim, the insured must fill up the pre-authorization form to be eligible for the cashless treatment. Insured should apply for the cashless treatments 48 hours prior to the pre-planned hospitalization and 24 hours prior to emergent hospitalization. You must remember that there must be some minor exclusion that should be paid by you.
As per the market researcher, TPA system has come up with problems in settling the claimed amount. Many insurance companies hire TPAs to limit the claims. The several instances are there where insured ones faced a tough time to get back their amount. After assessing all documents, it can be summed up as you should have a complete idea about who your TPA is and how professional the organization is for processing the claim. Go for the online research to get the insight detail about the company and TPA. Some insurance companies even have the facility of in-house settlement policy. They seem more reliable, but they also have a team like TPA to check your claim.