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Health Insurance Claims Process
Mar 7, 2024

A Guide on Time Limits in Health Insurance Claims Process

Having a health insurance plan in these times has become very crucial. As medical inflation rates increase, the need to have a financial backup for medical issues is paramount. Ishita, 29, is a young working professional who takes her finances and her responsibilities seriously. This is why she bought a health insurance policy for her parents only after thorough research and comparisons.
A health insurance plan offers more than just hospitalisation coverage. It allows one to have better peace of mind so that the focus can be on rest and recovery instead of financial woes.
To benefit from health insurance during a medical emergency, one has to raise a claim with the insurance company. Each company has a specified time limit within which you are expected to inform them about the medical issue and raise the claim.  To know more about the health insurance claim time limits, read on.

Understanding Health Insurance Claim Time Limits 

Firstly, it is important to note that claim time limits can differ from insurer to insurer. Even within one insurance company, the time limits may depend on the type of health insurance plan chosen.
With Bajaj Allianz General Insurance, the time limits for cashless and reimbursement claims are as follows:*
1. For cashless claims, the insured or their representative must inform the insurance company before 48 hours if they are opting for planned hospitalisation.
2. For emergency hospitalisation under the cashless facility, the insurance company must be informed within 24 hours.
3. In both cases, the insured or their representative must request pre-authorisation via from the eEmpanelled network hospital side.
4. For reimbursement claims, the insurance company must be informed by the policyholder or their representative 48 hours before the planned hospitalisation.
5. For emergencies, the time limit for reimbursement claims is also 48 hours. The insurer must be informed within this period after the hospitalisation takes place.
6. Additionally, insurance companies also have time limits for submission of documents. For instance, under the Health Guard plan from Bajaj Allianz General Insurance, the policyholder or someone on their behalf must submit the required documents for the reimbursement claim within 30 days of the discharge from the hospital.
Claims are subject to terms and conditions set forth under health insurance policy.

Cashless and Reimbursement Claims 

If you are not familiar with the terms ‘cashless’ and ‘reimbursement’ regarding health insurance claims, here is a brief explanation:*
  1. In a health insurance cashless claim, the medical hospitalisations bills are taken care of directly by the insurance company. The payment process is mainly handled between the insurer’s representative and the network hospital (i.e., hospitals empanelled with the insurer where cashless facilities are available).
  2. In a reimbursement claim, the policyholder pays the medical bills to hospitals and then files a claim with the insurance company.
Claims are subject to terms and conditions set forth under health insurance policy.

Why Time Limits Are Crucial for Health Insurance Claims 

Wondering what role time limits play in health insurance? Read on:

Allows faster claim settlement 

If you raise a claim on time, it allows the insurer to start the due process begin the verification process on time as well. In case the insurer requires additional details or documentation, they can request for the same, either from the insured or the network hospital and receive it on time. Delays in raising the claim could lead to eventualissues in the later processes as well delays in the settlement of the claim. Consider this: Your health insurance provider does not have a time limit. In such cases, if you are busy taking care of the patient, you may forget to raise a claim or delay it. This would slow down the entire process. The document submission would be postponed, and the reimbursement might be delayed, too.
Hence, having and following time limits in Health insurance is important for faster claim settlement.

Ensures swift payment 

When it comes to cashless claims, as explained earlier, the payment is handled by the insurer. If they receive the intimation or the cashless request on time, they will be able to inform the insured or the hospital for the further process (medical or otherwise) on time too. If the claim is not raised on time, the hospital dues will not be paid on time, either. In such a situation, the patient could face challenges with further treatment or discharge. Hence, time limits on health insurance claims are crucial.*
Claims are subject to terms and conditions set forth under health insurance policy.

Reduces chances of fraud

Time limits can help mitigate fraud claims. With a strict duration to raise a claim, fraudsters do not have enough time to create false information and raise fraudulent claims.

Important Points to Remember When Raising Health Insurance Claims

Now that you may have a fair idea of time limits, let’s look at other important aspects of health insurance claims:
1. If you have a family health insurance plan, make sure all the insured members are aware of the claim process. This includes the claim raising process as well as the time limits, documents to be submitted, essential contact numbers, and so on.
2. Be honest with your insurer. Insurance relies on good faith between all the parties involved. Hence, be truthful with your insurance provider about your medical history, any pre-existing illnesses, any major changes in lifestyle or medical updates, and so on.
3. Have all the necessary documents in one place. It is understandable that you might be busy with the hospitalisation procedures. However, please take some time to gather and organise the needed documents so that it is easier to raise a claim.
Claims are subject to terms and conditions set forth under health insurance policy.
Additionally, it is important to pay premiums on time. Before you buy a plan, remember to use a health insurance premium calculator.
* Standard T&C apply.
Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.

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