Mediclaim insurance policies provide financial protection against medical expenses incurred during hospitalization. However, to avail the benefits of an Individual health insurance policy, policyholders need to understand the claim reimbursement process. Here are 5 important things you need to know about claim reimbursements in Mediclaim:
1. Documents Required for Filing a Claim
To get reimbursed from a Mediclaim policy, key documents need to be submitted to the insurance company. A duly filled claim form provides treatment details while a discharge summary from the hospital outlines diagnosis and care received. Original bills and payment receipts are necessary as proof of expenses incurred. Identification documents with photos like Aadhaar or PAN card are also required for verification. Submitting these documents together ensures a smooth claim process. Incomplete documentation can cause delays or rejections, so policyholders should keep all records organized for quick reimbursement.
2. Timelines for Claim Settlement
Insurance regulators in India have defined maximum time periods for insurance companies to complete claim processing and payment. For simple hospitalization claims of up to Rs.30,000 (cashless claims), the full claim amount must be paid within 7 days of receiving all documents. Larger hospitalization claims (reimbursement claims) require a maximum of 30 days for processing and payment after documents submission. If there is any delay beyond these periods, insurers must pay monthly interest on the claim amount at 2% above bank rates. Policyholders should track claim status and address delays with the insurer.
3. Modes of Claim Payment
Insurers provide different digital options to policyholders for receiving claim payments swiftly. The approved claim amount can be directly transferred to the insured’s bank account usually within 24 hours. Some insurers also enable payment in popular e-wallets for added convenience. In cases where bank details are not available, a cheque is issued. During cashless claims, the settlement is made directly to the hospital. It is important for insured to ensure their bank/wallet details with insurer are correct to avoid delays in electronic claim receipts.
4. Claim Settlement Ratio
The claim settlement ratio is an important metric that shows an insurer’s ability to efficiently process medical reimbursement requests. It is calculated as the percentage of total claims paid out of total claims received. A ratio close to 100% demonstrates the insurer’s robust system and customer-focused approach in settling claims. A high ratio above 95% is considered excellent. This number gives policyholders an idea of the insurer’s track record in settling claims and reliability. People should check an insurer’s claim settlement ratio before purchasing a Mediclaim policy to evaluate their effectiveness in processing reimbursements.
5. Redressal of Claim Rejections
In the case of a claim rejection, policyholders can appeal the decision with the insurer for another review. Within 60 days of rejection, one can submit extra documents or explanations to the insurer. If the appeal is also denied, the matter can be taken to the insurer’s grievance redressal cell for an impartial re-examination. However, if the grievance cell’s decision continues the rejection, recourse is available by filing a complaint with the insurance. They will make a final ruling binding on both parties. This process helps policyholders in addressing unjust claim rejections.
Understanding these key aspects to claim the health insurance plans for family can help policyholders file claims smoothly and receive timely reimbursements from Mediclaim policies. Proper documentation and following up within stipulated timelines are important.