The increasing expenses of remedy have made taking wellness insurance coverage cover an absolute necessity. Ever due to the fact the outbreak of the Covid-19 pandemic, the demand for wellness insurance coverage has improved several fold.
With the surge in the quantity of Covid positive instances, hospitalisation and death through the second wave of the pandemic, the apparent query comes to thoughts if a wellness insurance coverage claim is admissible if an insured individual dies in hospital.
One of the standard eligibility needs associated to wellness insurance coverage claims is at least 24 hours of hospitalisation. So, an insurance coverage claim becomes admissible if an insured individual remains hospitalised for more than 24 hours following finding admitted or dies in hospital following 24 hours of admission.
But how to make a claim request when an insured individual dies in hospital?
“In case of the death of an insured, payable medical expenses per the insured’s policy terms and conditions will be settled by the insurer,” says T A Ramaligam, Chief Technical Officer, Bajaj Allianz General Insurance.
“There are two facilities that one can opt for while filing for Health Insurance Claims, i.e. Cashless Claims and Reimbursement Claims,” he explains.
Cashless Claims
If the client chooses a network hospital of the insurer for a health-related remedy, then cashless claims can be opted by the insured. The client demands to flash his wellness ID card at the Insurance/ TPA desk to avail the cashless facility at the empaneled hospital. The course of action is then initiated involving the hospital & the insurer exactly where the client is kept informed on the progress at just about every stage and the choice on the request received. Highest priority is accorded to the COVID – 19 instances.
Cashless Claim Process
1. In case the hospital admission is planned, consumers ought to method the insurance coverage desk of the hospital which guides them in a cashless facility. The insurance coverage desk forwards the complete case with pre-authorisation application kind (which is countersigned by the treating physician) to the insurer. Basis the case facts and policy T&C, insurer approves the cashless facility. Generally, this approval ought to be taken 4 – 7 days prior to the remedy.
2. If you connect with your insurance coverage enterprise, they will inform you about the documents that might be essential. Post sharing these documents and health-related facts with the insurer by way of the insurance coverage desk, it evaluates the remedy facts as per policy terms and situations and informs the concerned hospital and insured.
3. The client demands to create following documents at the network hospital in addition to the documents that are specified by the insurer:-
a.i. Pre-Authorisation Letter (completed by insurance coverage desk)
a.ii. ID card issued by the insurance coverage enterprise or Health Insurance Policy
a.iii. Aadhar Card, Pan card / Form 60 (For KYC goal)
4. Once the remedy is performed and the client has availed the cashless facility, the original bills and remedy proof ought to be left with the hospital. The hospital shares these bills with your insurance coverage enterprise and accordingly payment is processed by the insurer to the hospital.
5. In case of any unplanned or emergency health-related remedy, the policyholder can just get in touch with the insurer by way of its client care center or chatbot facilities to know about the empaneled hospitals. Once at the hospital, the client can request for cashless hospitalisation by generating the insurance coverage card offered by the insurers along with the policy copy to the insurance coverage desk.
6. Once the client tends to make this request, the hospital connects with the insurance coverage enterprise by filing the pre-authorisation request kind and consequently the insurer problems an authorisation letter to the hospital. Insurer also shares facts pertaining to the policy coverage of the client.
7. Once the remedy is more than, the insurer will then settle the payment of admissible claims.
Covid Carnage: IRDAI urged to raise time limit for submission of insurance coverage claim documents
Reimbursement Claims
If the client chooses a hospital which is not empaneled with the insurer, then the claim is settled on a Reimbursement basis. On receipt of the full set of documents as requested by the insurer, reimbursement claims are settled generally inside 5 days. For instance, Bajaj Allianz General Insurance has launched a one of a kind facility wherein consumers can now instantaneously submit digital documents by way of the company’s self-service mobile application – ‘Caringly yours’ for assessment and settlement. Through this new facility, a wellness insurance coverage client can now acquire their claims inside 5 working days.
Reimbursement Claims Process
1. The insured can download the claim types essential from the insurance coverage company’s web page or can be collected from any of the offices/intermediaries of the insurer.
2. The client is essential to provide vital documents along with the original health-related bills to the insurer at the time of claim filing. These documents generally incorporate a claim kind, bank facts, ID cards, hospital discharge summary, investigation and diagnosis reports and bills, original hospital and pharmacy bills along with paid receipts and prescriptions. Additionally in case of an accidental hospitalisation, a copy of FIR might also will need to be shared with the insurer.
3. The insurance coverage enterprise evaluates the claim basis of the documents following confirming the T&C below the policy.
4. Post the evaluation the insurance coverage enterprise tends to make the payment to the beneficiary as per policy terms.
5. On non-receipt of particular mandatory documents, the insurer can ask for these further documents to take a choice on the claim.
6. In case of claim repudiation, the insurer delivers the grounds on which the claim is non payable.
“We have enabled digital mode for claim submission in our Caringly Yours App, Website & Portals for the ease of our customers which can be accessed from the comfort of their homes. All that needs to be done is click the pictures of claim documents and follow the prescribed guideline for submission. This also provides real time assistance to the customers through various communication channels such as Contact Centre, WhatsApp, Educational Videos etc,” says Ramaligam.