When it comes to safeguarding our health, nothing truly counts as much as a good mediclaim policy. It acts as a safety net, shielding us from the hefty medical trials and tribulations that life may throw our way. However, despite the clear benefits, the complexity of the claim process often leaves policyholders perplexed. If mediclaim policies are daunting to you, this primer aims to clarify the claim process for mediclaim policies.
The mediclaim policy, which falls under the broader umbrella known as health insurance, works on the fundamental concept of indemnity. This means that it offers coverage for hospitalization and treatment expenses incurred by the insured person as a result of a medical emergency or a planned treatment. The coverage is subject to the sum assured, which is selected by the policyholder at the time of purchasing the policy.
So, how exactly does the claim process work? Let’s break it down.
There are primarily two types of mediclaim: cashless and reimbursement. They each have their own claim process.
1. Cashless Claim Process
A cashless claim is one of the significant benefits of mediclaim policies. It means that the policyholder does not need to settle the bill upfront with the hospital. The insurance provider will directly settle the hospitalization expenses with the network hospital where the insured is getting treated.
The process commences with the policyholder or a relative notifying the insurer about the hospitalization. In planned hospitalization scenarios, these formalities need to be completed a few days in advance. In emergencies, the insurer should be informed within 24 hours of hospitalization.
Following this, a pre-authorization form must be filled out, providing essential details about the policyholder and the nature of the treatment being sought. Once the forms are verified by the third-party administrator (TPA) or insurer, approvals are sent to the hospital, after which the treatment can commence.
However, keep in mind that insurance companies may deny cashless hospitalization based on exclusions in the policy, such as pre-existing conditions, waiting periods, or non-coverage of certain diseases.
2. Reimbursement Claim Process
In cases where the insured cannot avail of the cashless facility or opts for treatment at a non-network hospital, the policyholder has to bear the cost of treatment initially. These costs can be claimed from the insurance company through the reimbursement process.
Documentation plays a significant role here. The policyholder needs to provide all original hospital, pharmacy, and diagnostic bills, along with the discharge summary, doctor’s report, and all other relevant medical records. The completed claim form along with these documents needs to be submitted to the insurance company.
The insurer will then verify the documents. If the claim meets the terms and conditions of the policy, the reimbursement gets approved, and the assured sum is transferred to the policyholder’s bank account.
Mediclaim policies and health insurance are our companions in the battle against unexpected medical exigencies. Understanding how to claim mediclaim, however, is a crucial responsibility of every policyholder. It empowers us not just to select the right policy, but also to handle emergencies with preparedness and confidence. Therefore, understanding the mediclaim claiming procedure is as vital as having medical insurance itself.
If mediclaim policies are daunting to you, this primer aims to clarify the claim process for mediclaim policies. For a streamlined experience, consider using the Bajaj Finserv app. Download Bajaj Finserv app to easily manage your mediclaim policy and claims.
Being aware of your policy terms, vigilant during documentation, and prompt in communication with your insurer are key elements in ensuring a smooth and successful claim process. So, read your policy details meticulously and ask questions if you’re not sure about anything. After all, it’s your health and hard-earned money at stake.
