Health insurance is an option chosen to protect one’s finances during unexpected or sudden health emergencies and planned medical procedures for expected treatments. But the expectations and goals can be delayed or halted if there is inaccuracy in informing the insurer.
We are talking about the reimbursement claim form that acts as a source of information for the insurer to verify your claim. Requiring detailed information and submission of all the relevant documents, there are multiple areas prone to mistakes.
The best way to avoid them is by knowing the mistakes. Considering its essence, here we will be listing the possible mistakes and how to avoid each of them individually. So, if you are wondering how to fill reimbursement claim form before actually going to fill one, scroll down now!
Common Mistakes that Reject Reimbursement Claims and How to Avoid Them
Reimbursement claims are made after the insured person has received the treatment. It involves submitting the complete information to the insurer for reimbursement of the medical expenditure. The claim requires filling out the form and providing all the medical documents.
If the insurer finds something missing or inaccurate, they can reject the claim. Hence, ensuring careful approach beforehand prevents the challenges later. Here is what to be careful about:
Inaccurate Patient Information
Spelling mismatch in the name, digit or letter mismatch in the patient ID or treatment date, incorrect insurance ID numbers and wrong demographic details prevent a smooth verification process. It can delay the claim process and even lead to rejection.
How to Fill Reimbursement Claim Form to Avoid Inaccuracy:
- One of the most important and first things to do is to ensure all your existing ID cards, like Aadhar, PAN and bank account information has correct spelling of your name.
- While filling the claim form, first match the spellings and then write accordingly.
- Regularly verify the bills, reports and other documents while receiving to ensure on-the-spot correction of the details if they are wrong
- Double-check that the submitted documents have correct spellings and details
Missing Documents
The reimbursement claim form requires multiple documents to be submitted for thorough analysis and verification. The list includes:
- Final hospital bill
- Original discharge summary comprising details of the medical condition
- Consultation papers
- Diagnostic and investigation reports
- Report issued by a medical examiner
- Original pharmacy bills with prescription
- Original investigation bills for pre/post-hospitalisation expenses
- Implant invoice or sticker
- All original payment receipts
- Indoor case papers
- ID proof
- CKYC and bank details
- Medico-Legal Certification (MLC) report
- FIR
- Written explanation for the delay (if applicable)
Absence of any of the documents that is necessary for the policyholder will result in a delay in processing or may also lead to claim rejection by insurers. It is because the insurance company would not be able to verify the medical necessity of treatments, the diagnosis of the medical condition or the validity of expenses.
In some situations, the insurer may request further documents, and the inability to submit them in a timely manner can further lead to claim rejection. Also, a consequence can be that the insurer may pay only for items that can be verified, while rejecting the rest of the claim.
How to Fill Reimbursement Claim Form to Avoid Missing Documents:
- Have prior access to the required documents by downloading the checklist from the insurer
- Ask for all the original, signed and stamped documents directly from the hospital before leaving
- Also, request from the hospital for a broken-down bill rather than the single total amount
- Keep note of which documents are required in original and for which copy of the original documents is accepted
- Remain updated about the status of the claim and the requirement for missing documents to arrange and submit them immediately
- Keep a photocopy of all the documents you submit for reimbursement claim
- Ensure to submit the documents within the stipulated time as stated by the insurer
Claim for Uncovered Medical Conditions
Oftentimes, the reimbursement claims are rejected because the medical conditions are not covered in the policy or are listed under exclusions, and the fact is not known to the insured. These include experimental treatments, cosmetic surgeries or others as mentioned in the policy.
Sometimes, the applicant may submit claims for pre-existing conditions during the waiting period or for lifestyle-related illnesses. These claims will not be entertained by the insurer depending on policy terms, disclosures, exclusions or non-disclosure of habits
How to Fill Reimbursement Claim Form to Avoid Misinformation/Lack of Information:
- The rejections or less than expected payments may occur due to not properly reading and understanding the policy. Hence, thorough information about every aspect, including coverage and finances, is necessary while choosing a health insurance policy.
- Keep a record of every expenditure and the necessary documents like original medical bills, reports and prescriptions.
- Understand the do’s to know what is expected from you and the don’ts to avoid actions that can violate or invalidate the policy.
- Know the exact timelines and process beforehand.
- Plan the scenarios and possibilities beforehand.
Incomplete Bank Details
While you are waiting for the approved claim to reimburse the amount, there can be an unnecessary delay in processing the funds. It may arise due to filling in the incomplete or wrong bank details in the claim form.
The corrections here can be easily done if the claim has been submitted but not processed.
How to Fill Reimbursement Claim Form to Avoid:
- Cross-check the filled information letter by letter and digit by digit
- In case the wrong data has been filled, immediately inform the insurer
- Be active in tracking the claim process and resubmit the details as per the request
Claiming Beyond the Coverage
Policyholders may end up claiming for the amount beyond what’s promised in the policy coverage. Alternatively, they may raise a claim for bills/charges listed in exclusions in the policy. These generally include room rent, non-medical items or other non-admissible expenses. The insured may also request reimbursement beyond the sub-limit for specific diseases or the maximum payment limit mentioned in the policy.
Similarly, filing the reimbursement claim form without understanding the co-payments, which is the percentage of the total claim and the deductible, which is the fixed initial amount to be paid out of pocket, can result in a lower reimbursement than expected.
How to Fill Reimbursement Claim Form to Avoid Claiming Beyond the Coverage:
- Check the policy details before filing the claim form to avoid making claims that are against or exceed the policy rules
- Separate non-payable items such as toiletries, food for attendants or convenience charges from the final bill before submitting the claim
- Consider claiming pre-hospitalisation and post-hospitalisation expenses only if they are allowed as per the policy terms
- Contact the insurer or Third-Party Administrator (TPA) before submission if there is confusion or a query regarding filling the form or claims to be made
Conclusion
A reimbursement claim becomes easier to submit if accuracy, clarity, planning and timely action are considered right from the beginning. Small mistakes, casually filling the form without focus, not reading or understanding the policy terms, and inappropriate claim amounts can pose challenges and lead to a delay in processing the form.
Avoiding the issues is possible by working on the mentioned common problems. Further, we recommend contacting the insurer or TPA for updates and clarification of the doubts as per the necessity. But the most important advice is to understand and accordingly prepare for the reimbursement claim filing process beforehand. This reduces stress, saves time and helps receive the eligible amount without any hassle.
FAQs
1. What is the moratorium period in health insurance?
The moratorium period in health insurance is a five-year continuous no-lapse period. After this period, the insurers cannot reject claims due to non-disclosure or pre-existing conditions (PEDs). However, the claims can still be denied in the case of proven fraud.
2. What to do if a pre-existing disease is found which I was unaware of?
If a pre-existing disease is found, then inform the insurer in writing with medical records showing when it was diagnosed. Disclose it at renewal and review the waiting period terms. Genuine awareness is considered with the existing insurer as well. Alternatively, you may also switch the insurer and declare the condition to the new insurer.
3. How long does a reimbursement claim usually take?
Reimbursement claim processing time differs across insurers. It varies from 7 to 30 working days to analyse and verify the documents. Generally, the simple claims resolve within a week while complex cases take longer. The claims can be tracked online from the insurer’s portal.
4. Can I submit a reimbursement claim online?
Yes, you can submit reimbursement claims online. It can be done through the insurer’s app or website. Ensure to submit the claim within the stipulated time provided by the insurer.
5. What is a claim authorisation letter?
A claim authorisation letter is a formal document allowing an insurer, hospital or representative to process, discuss or receive reimbursement claim information on behalf of the policyholder. It is commonly used when someone else handles the claim due to an emergency or convenience.