Claim Settlement in Health Insurance: The Actual Game Changer

• Written by Gungun Bhatia

  Reviewed by Munmi Sharma

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Imagine this: Sandeep, a 38-year-old IT professional, has always prided himself on being financially prudent. He bought a health insurance policy for his family five years ago and felt secure. One day, his father suffered a heart attack and doctors admitted him to a hospital. Sandeep breathed a sigh of relief, knowing he had a Rs. 10 lakh health insurance plan.

But things quickly spiralled into chaos when his claim was only partially settled. The hospital left Sandeep with a Rs. 2.5 lakh bill.

Sandeep's story isn't unique. Many policyholders believe that owning a health insurance plan is enough. However, the claim settlement experience truly tests the value of any policy.

In this blog, we'll explore why health insurance claim settlements are essential, factors affecting it, mistakes made by policyholders, and much more. So, let's start.

Understanding Claim Settlement in Health Insurance

Claim Settlement is when an insurance company pays the insured amount to the policyholders for medical expenses covered under the policy. It is the moment of the truth for your health insurance policy, where the purpose of buying the policy is either fulfilled or failed.

There are various methods of claim settlements:

• Cashless Claims: In this case, the insurer pays the hospital directly, so you don't have to handle any upfront costs.
• Reimbursement Claims: In this case, you pay the bill first and then submit it to the insurer for reimbursement.

No matter what type of insurance you have, how simple it is to settle a claim, and how transparent the process is, it shows how good your coverage is.

Why Claim Settlement Deserves More Attention?

While buying health insurance, most people focus on premium costs, coverage limits, and add-ons. However, individuals often overlook the settlement of the claim until it becomes critical. Here's why it deserves a front-row seat in your decision-making process:

Is Your Policy Up to the Task

The real test of your policy is whether it can help you financially when a medical issue arises. If your insurance company takes too long or fails to settle your claim, you won't get the support you need.

Peace of Mind in Critical Moments

When you're in the hospital, your main goal should be to recover, not to fight with your insurer. A smooth claims process can ease the stress you may endure during such a situation.

No Surprise Bills

Delayed or rejected claims can force you to use personal savings or take loans. Efficient claim settlement ensures your expenses are covered as promised, avoiding this financial burden.

Pay Attention to Claim Settlement Ratios

The Claim Settlement Ratio (CSR) shows how many claims an insurer has settled compared to how many it received. A higher CSR usually means the insurance company is reliable. For instance, if an insurer has a CSR of 97%, that shows they're settling 97 out of every 100 claims. The higher the CSR, the better it is.

Important Things to Consider for Claim Settlement

Knowing what affects your claim settlement process can help you make smart choices and dodge any nasty surprises.

Transparency of the Policy Document

If the policy terms are confusing or have a lot of fine print, your claim could get rejected. Ensure you know what's covered, what's not, and when your claim will be accepted.

Pre-Authorisation Procedures

Getting pre-approval from the hospital and the insurer on time for cashless claims is essential. If you miss this step, your claim could be delayed.

Submission of Documents

One big reason claims are denied is missing or incorrect paperwork. Always correctly gather and send discharge summaries, bills, prescriptions, and reports.

Network Hospitals

Going to a network hospital can make cashless claims easier. If you go to a non-network hospital, you might have to pay first and then deal with a longer reimbursement process.

Policy Exclusions & Waiting Periods

Insurance coverage does not cover permanent exclusions like cosmetic surgery and self-inflicted injuries. Before buying insurance, it is crucial to review the exclusions list to prevent claim denials.

Common Mistakes Policyholders Make

When you have a reliable insurance company, settling your claims can still be tricky. Sometimes, simple mistakes can wrench the claim settlement process and delay everything. Let's discuss these mistakes:

Not Mentioning Pre-existing Conditions

Your claim could be denied if you don't mention existing health issues when you buy the policy.

Overlooking Waiting Periods

Most policies have a waiting time for specific illnesses or issues that existed before you got the policy. Trying to claim during this time can mean a denied claim.

Poor Record-Keeping

If you misplace your medical bills or reports could seriously impede your claim or even nullify it. To avoid these problems, ensure you have a physical and digital copy of everything.

Choosing the Cheapest Policy

Going for the lowest premiums might mean getting less help with claims later. It's smart to balance price and how well the insurer handles claims.

Tips to Ensure Smooth Claim Settlement

Here are some helpful tips for making sure that your health insurance works as it should when you need it:

Pick the Right Insurance Company

Find insurance providers who have an impressive record for settling claims quickly. High claim settlement ratios indicate that they are dependable in their payments, which is what you desire. A little research can go a long way here.

Stick to Network Hospitals

Always visit hospitals that are part of your insurance network. This will make the claim settlement process easier without the hassle of paperwork.

Know Your Policy Inside and Out

Before you ever need to file a claim, read your policy document. It's essential to understand what's covered and what's not. If something isn't clear, don't hesitate to ask questions. Reach out to your agent or contact the insurance company directly for clarification.

Keep All Documentation

From the moment you are admitted to the hospital until you are discharged, make sure you collect all the paperwork related to your treatment. This includes bills, discharge summaries, and any other relevant documents. Keeping everything organised will make the claim process smoother.

Inform in Advance

If you have a medical emergency or plan to visit the hospital, inform your insurer immediately. Early notification can help speed things up, so don't wait until the last minute.

Stay on Top of Things

It's helpful to be proactive during the claim process. If your claim takes time, don't hesitate to contact your insurance company or the Third-Party Administrator (TPA) handling it. A little follow-up can help push things along if there are any snags.

Now, the question is which healthcare provider to choose. Care Health is one of the best healthcare insurance providers. Let's discuss why.

>> Also Know: Incurred Claim Ratio in Health Insurance

Why Care Health Insurance Stands Out

Choosing a trustworthy insurer is half the battle won when it comes to claim settlement. Care Health Insurance (formerly Religare Health Insurance) is one of India's most reputable health insurance providers. It is known for its transparent processes, customer-first approach, and high claim settlement ratio.

Here's why Care Health Insurance is a Smart Choice:

• High Claim Settlement Ratio
• Pan India 21,700+ Cashless Healthcare Providers
• Digital Claim Process
• Transparency
• Wide variety of Insurance plans
• 58 Lakh+ Claims Settled

Don't Just Buy Insurance - Buy a Promise

Fundamentally, insurance is about trust—the assurance that you will not have to confront life's unexpected turns alone. The insurer's ability to fulfil that commitment through prompt and equitable claim settlements determines how good that guarantee is.

Therefore, do not limit your comparison of health insurance plans in India to their price or extent of coverage. Examine the insurer's customer experiences, ratios, and claim settlement procedures in further detail.

Disclaimer: All plan features, benefits, coverage, and claims underwriting are subject to policy terms and conditions. Kindly refer to the brochure, sales prospectus, and policy documents carefully.