How do I make a claim in case of an insurance event? I have a cashless mediclaim from United India but somehow I am not able to understand how I should initiate a claim settlement in case of hospitalisation. Could you please give me step-by-step procedure for filing claims and reimbursements?

Ans: Hi Vilas, in order to understand the difference in the estimated costs, you should ask the hospital on what parameters they have estimated the two costs. Questions on treatment protocol, room charges and type, doctor’s fee etc., should be asked.

When choosing cashless treatment, the patients often opt for the best facilities that they may not have opted for otherwise. Sometimes hospitals may run some additional tests as well in order to avoid back and forth on your claim settlements, when it is a direct transaction between insurer and the hospital.

However, if you feel that you are being overcharged, then you should report any discrepancy in what you are being charged for, to the insurer. Insurance companies take such cases very seriously, which is why insurers have preferred network hospitals that agree on a certain pricing for various treatments and other tariffs.

In case it is observed that there is any abuse of cost or sum insured then there is a chance of being de-paneled and hence a check is in place.

Ans: Hi Chiraag, hope reading my answers cleared your doubts. To answer your personal query, the insurance company must have mentioned in your policy document that to raise a claim under your policy, you will need to be admitted for minimum 24 hours and without that the claim will not stand.

Also, the treatment in this case needs to be done in an AYUSH recognised hospital to avoid failure of claims.

Ans: Hi Vijay, thanks for your wishes. All insurance policies cover pre- as well as post-hospitalisation charges. However, the coverage period for pre- and post-hospitalisation differ insurer to insurer.

Request to check your policy document to know the period covered by your insurer for post hospitalisation claim.

Ans: Hi Anand, very sorry to hear about your plight. Seeing that you are not getting any response from the insurer, my advice would be that you approach ombudsmen and register your complaint. You need to email them at complaints@irdai.gov.in with your query along with all the documents of your case.

Ans: key things to consider before choosing a family health insurance plan with cashless coverage:

Family Coverage:

Member inclusions: Ensure the plan covers all your immediate family members (spouse, dependent children, and potentially parents depending on the plan).
Sum Insured: Choose a sufficient sum insured per person considering potential medical inflation and future healthcare costs. Opt for a joint sum insured or individual sum insured per family member based on your needs.
Cashless Network Hospitals:

Network breadth: Research the insurance company's network hospitals in your area. Accessibility and quality of hospitals within the network are crucial factors.
Cashless claim settlement ratio: Check the company's cashless claim settlement ratio, indicating the percentage of cashless claims approved. A higher ratio indicates smoother claim processing.
Policy Coverage:

Hospitalization expenses: Ensure the plan covers hospitalization bills, including room rent, surgeon fees, medications, and other related costs.
Pre-existing conditions: Look for a plan that covers pre-existing conditions if any family member has one. However, there might be waiting periods for coverage.
Daycare expenses: Some plans offer coverage for daycare expenses incurred during hospitalization.
Co-pay/Deductible: Some plans involve co-pays (fixed amount paid for specific services) or deductibles (amount you pay before insurance kicks in). Understand these clauses and choose a plan with terms that suit you.
Claim Settlement Process:

Claim settlement turnaround time: Research the average time the insurance company takes to settle claims.
Claim intimation process: Understand the claim intimation procedure and required documentation to ensure a smooth process.
Company Reputation:

Financial stability: Choose a health insurance company with a strong financial track record for claim settlements.
Customer service: Look for a company known for good customer service, especially regarding claim processing assistance.
Ways to Research Plans & Claim Coverage:

Company Websites: Most insurance companies have detailed information about their health insurance plans on their websites.
Insurance Comparison Websites: Websites like Policybazaar (https://www.policybazaar.com/), CompareRaja (https://health-plan-compare.com/), or Fincare (https://www.insurancedekho.com/health-insurance/news/religare-health-insurance-partners-with-fincare-small-finance-bank-7) allow plan comparisons and provide valuable insights.
Insurance Agents: A licensed insurance agent can help you compare plans, understand exclusions, and choose the one that best suits your family's needs.
Understanding Exclusions:

Most health insurance plans have exclusions, which are medical expenses the plan doesn't cover. Here's how to learn about them:

Policy Wording: Read the policy wording carefully, focusing on the exclusions section. This will clearly outline what isn't covered by the plan.
Speak to the Insurance Provider: Contact the insurance company directly and ask about any exclusions related to specific procedures or pre-existing conditions.
Choosing the Right Plan:

Don't just focus on premiums: While cost is important, prioritize comprehensive coverage over just the lowest premium.
Get quotes from multiple companies: Compare quotes from different providers to find a plan that offers the best value for your needs.
Ask questions: Don't hesitate to ask questions and clarify any doubts you have about the plan details or claim settlement process.
By considering these factors and thoroughly researching your options, you can choose a family health insurance plan with cashless coverage that provides peace of mind and financial protection for your loved ones.