Page 216 - DCOM309_INSURANCE_LAWS_AND_PRACTICES

Unit 12: Health and Catastrophe Insurance

12.3 Claim Settlement Procedure Notes

You need to know about the details of the claim settlement procedure. The claims that arise in
case of health insurance can be settled in any of the following ways:
1. Reimbursement of expenses.

2. Cashless facility for planned hospitalization.
3. Cashless facility for emergency hospitalization.
The claims are defined as follows:
1. Reimbursement of expenses: If a policyholder falls sick and hospitalized in non-empanelled
hospital then he should follow the following procedure:

Intimation to the insurer/Third Party Administrator (TPA) along with the name of
the person who has fallen sick
Policy number
Name of the hospital

Name of the doctor
The above information should be sent within 7 days of the hospitalization.
Within 30 days final claim form should be furnished along with the following documents:
Hospital receipts/original bills.
Cash memos.
Various reports and tests.
Hospital admission and discharge slip.

Case history.
Any other documents desired by TPA or hospital.

Notes It is a must to ensure that insured person has been admitted to a hospital/nursing
home as defined in the policy.
2. Cashless facility for planned hospitalization:

The expected expenses to be incurred should be sent to TPA through the agreed list
of network hospital,
Policy no. and card number should be shown to the hospital,

On confirmation from the TPA the treatment can be taken in that hospital,
If expenses increase during the treatment then the hospital will sent revised estimate
to the TPA for their approval,

For any post hospitalization treatment the original bills/cash memos can be sent to
the TPA after completing the treatment for the reimbursement.
3. Cashless facility for emergent hospitalization

A card issued by the insurer should be shown to the hospital.
The expected expenses may send to the TPA for their approval.

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