Once the patient is discharged from the hospital, in case of a cashless claim, the insurer settles the bill. However, in case of a claim on reimbursement, the insured has to pay all hospital bills and collect the original documents of the treatment undergone and expenses incurred. Along with some other documents, they have to be sent to the insurer to get them reimbursed.
Some of the indicative list of documents that needs to be sent includes
•Filled up claim form along with the original discharge summary,
• Doctor's consultation reports, hospitalisation and other medical bills,
• Receipts in original,
• Investigation reports, self-declaration or an FIR in case of accident cases.
It's better to get the list of required documents from the insurer as each one would have its own specific list. The insurer may ask or additional documents, so follow up with them to ensure that they have received all required documents.
If the hospital is not registered, you will need to get information such as the number of beds, availability of doctors and nurses round the clock and its registration number on a paper with the hospital's letterhead on it. In case of non-network hospital, you may have to get the hospital and doctor's registration number in hospital letterhead and get the same signed and stamped by the hospital.
The claim settlement timeline According to the Insurance Regulatory and Development Authority of India (IRDAI) guidelines, an insurer has to settle a claim within 30 days from the date of receipt of the last necessary document. In the case of delay in the payment of a claim, the insurer is liable to pay interest from the date of receipt of last necessary document to the date of payment of claim at a rate 2 percent above the bank rate.
However, the insurer may initiate an investigation before paying the claim. Such an investigation has to be initiated at the earliest, i.e., not later than 30 days from the date of receipt of last necessary document. In such cases, the insurer has to settle the claim within 45 days from the date of receipt of the final document. If they delay it beyond 45 days, the insurance company will have to pay the policyholder an interest at a rate of 2 percent above the bank rate from the date of receipt of last necessary document to the date of payment of claim.
What you should do
In order to keep the claim settlement process smooth, it is not enough to just disclose all material health information to the insurer at the time of buying the policy but even intimating the insurer with the requisite information at the time of admission in a hospital plays an important role. So if you or a family member is getting admitted in a hospital, make sure you have all the required paperwork handy and know the claims settlement process of the insurer. If it so happens that it is not a network hospital or if the particular procedure is not covered, you will have to pay up the hospital bills upfront and get the amount reimbursed later.