Health Insurance Plans

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What is Health Insurance?

A contract requiring an insurer to pay part or all of an individual’s healthcare bills in exchange for a premium is known as health insurance. More specifically, health insurance often covers the insured’s medical, surgical, prescription drug, and dental expenses. Health insurance can pay the care provider directly or compensate the insured for expenses incurred as a result of illness or accident. It’s frequently included in employee benefit packages as a way to entice top talent, with premiums partially covered by the business but frequently withheld from employee paychecks. With limited exclusions for S company employees, the expense of health care premiums is eligible for deduction to the payer, and the advantages obtained are tax-free.

health insurance

Benefits of health insurance

  1. Lump Sum Payout: If an incident covered by the policy happens, the insurance provider will pay out the guaranteed sum assured. This is paid regardless of the actual cost of treatment.
  2. No restrictions: These health insurance policies give customers unlimited freedom to choose their favorite facility. He or she can be hospitalized at any medical facility because the set benefit is given out when the illness occurs. If you are diagnosed with a major sickness covered by the policy, you will be paid immediately without having to substantiate your claims with medical bills.
  3. Non-Medical Fees: When possible, non-medical costs and additional requirements after treatment can be compensated with this lump sum settlement. This includes medications, caregiver expenses, transportation costs, and much more.
  4. Affordable premiums: Fixed benefit health insurance plans typically have cheaper premiums, making them more accessible to a greater segment of the population.
  5. Fixed premiums: You can insure yourself for a longer period of time and the rates will stay the same.
  6. Tax Benefits: You can deduct up to 25,000 in health insurance premiums payable for yourself and your relatives under Section 80D of the Income Tax Act. If the insured is over 60 years old, the amount increases to $50,000. You can receive the same benefit for health insurance premiums paid for policies that cover your parents, up to 25,000 for parents under 60, and up to 50,000 for parents over 60.1.

Reason to choose PTIC

PTIC INDIA provides an extensive range of Health Insurance Plans and Mediclaim Policies, guaranteeing strong financial protection during medical emergencies. Given the increasing number and complexity of health issues stemming from evolving lifestyles, possessing a comprehensive health insurance plan is crucial. Neglecting to include health coverage in your financial planning creates a significant gap, underscoring the importance of prioritizing health insurance.

How to claim health insurance?

It’s essential to understand how to file a medical insurance claim in both cashless as well as reimbursement settings.

In the case of a cashless claim, the insured does not have to pay any money at the hospital counter upfront. The insurance will pay the hospital immediately on behalf of the insured. The cashless health insurance service is only available if the hospital has a contract with the insurance company or if the illness is covered by the terms and conditions of the insurance policy.

If the cashless claim option does not work out, the insured can choose the reimbursement claim option, in which the insurance company will refund the insured for the treatment costs they paid out of pocket afterward.

For cashless claim 

  1. Check and pre-inform: If you are planning a hospital stay, check with your insurance carrier to see if they have a relationship with the hospital where you will be treated. You should also double-check that the insurance company’s terms and conditions cover the illness for which you’re about to receive treatment.
  2. Form for pre-approval: It is necessary to go to the hospital’s Third-Party Administration desk and fill out a pre-authorization form whenever you wish to claim insurance money. This form notifies your insurance carrier that you want to make a claim on your coverage. After that, the hospital will send the form to the insurance company.
  3. Documents: At the Third-Party Administration counter, you would be required to submit your Cashless Health Card and specific KYC papers for verification of identity after submitting the pre-authorization form.
  4. Letter of Authorization: When the insurer obtains the paperwork seeking a cashless claim, it will send the hospital an authorization letter stating whether or not the claim will be processed. The insured will be alerted to their registered mobile number and e-mail address if their claim is denied.

In case of reimbursement claim

If the insurer does not provide cashless claims, or if the insured is unable to use the cashless claim facility for any other reason, the insured will be responsible for paying the medical expenditure out of pocket, which the insurer will reimburse later.

The following steps should be kept in mind while filing a refund claim:

  1. Make a claim for compensation: Within 30 days of being discharged from the hospital along with the hospital stamp, the insured must file a reimbursement claim with the insurance carrier.
  2. Documents: The insured must gather all pre-and post-hospitalization bills and reports for which he is filing a claim, as well as the hospital’s stamp. He must submit this health insurance paperwork, along with the claim form, to the insurance company. The records must include the patient’s name, the date of admission, and the doctor’s prescriptions.
  3. Form of discharge: The insured must transmit the discharge form he received from the hospital to the insurance company when he is discharged from the hospital.
  4. Wait for your payment to be processed: It may take up to 21 days for the insurer to process and examine all of the documents once they arrive. If the claim is denied by the insurer, the insured will be informed through email and a text message on the registered phone number.

How to claim faster

Here are five crucial pointers that enable you to make your health insurance claim procedure go faster and smoother:

1.Set Initiation of a claim on time: In the case of a reimbursement claim, the first action that must not be overlooked is notification. It necessitates the policyholder to notify the insurer of the patient’s hospitalization and, as a result, the impending claim. You must submit an intimation, which could be sent via email, phone, or your insurer’s website.

  • In the case of a planned hospitalization, 3-4 days previous to the patient’s admittance.
  • In the event of emergency hospitalization, within 24 hours of the patient’s admittance

The insurance company will raise a query if the insured fails to send a claim notification. You can, however, resolve the query provided you have a good rationale.

2.Get pre-authorization: The process of developing trust among the insured and the insurer is referred to as pre. Prior to initiating a cashless claim, the hospital verifies the claim’s eligibility by sending the policyholder’s pre-authorization form to the insurance company. The insured must provide their original identity proof as well as their insurance policy card to the hospital in order to obtain a pre-authorization.

The most important step, however, is to correctly complete the preauthorization form, which is used to determine your eligibility for a cashless claim. Here are some key points to bear in mind:

  • When filling out the form, do not use acronyms; the information in the forms must be properly deciphered.
  • If the hospitalization is pre-planned, get claim assistance from a claim expert.
  • Attach the relevant documents in the right order as outlined in the policy.
  • Justify your claim in the preauthorization form by adding the following information:
  • The cause for your hospitalization or your medical history
  • The treatment strategy
  • The amount of days patient will be admitted to the hospital for treatment
  • Estimated treatment costs
  • Doctor’s qualifications

3.Timely resolve your queries: In the case of a reimbursement claim, in case the insurance company uncovers a discrepancy in the insured’s documentation or medical condition, it presents a question that the insured must address. Moreover, the majority of medi-claimprocesses fail because the insured fails to respond to the insurance company’s inquiry in a timely manner. The policyholder receives three reminders from the insurance. If they do not remedy the issue after three reminders, their claim will be rejected. Therefore, in addition to replying swiftly to the inquiry, here’s what you’ll need to do:

  • Follow the claim settlement procedure by contacting the insurance company or TPA (if applicable) through phone or website. This will assist you in resolving the issue if you happen to miss the reminder.
  • Present all of the supporting documents in regard to the inquiry to clearly represent your case.

4.Establish trust: The majority of the patients make errors while filing a claim, which cost them a lot of money. And it’s all because of carelessness. They anticipate that the lack of a single document will have no consequence on the process because the insurance policy will have to reimburse the treatment costs nonetheless. And, in most circumstances, this sense of entitlement leads to claim rejection.

The relationship between the insured and the insurer influences the health insurance claim procedure, no matter how methodical it is. As a result, reporting all relevant information throughout the claim settlement procedure is just as critical as disclosing any pre-existing conditions when purchasing the insurance. As proof of honesty, you must present all of the original documents specified in the insurance policy, in a proper sequence, to minimize the chance of human mistakes on the part of the insurer. The following documents are included in the package:

  • Original Hospital Discharge Summary with a copy of your government-issued ID and your insurance card
  • Itemized Bills in Their Original Form
  • Bills from the hospital and the end of a relationship
  • Original Reports of Investigation
  • Original Pharmacy Statements
  • Authentic Prescriptions
  • FIR/Medico-Legal Certificate Copies (only in case of accidental injury)
  • Original Cheque Has Been Canceled

5.Contact a claim expert: The insurance policy certificate is a sophisticated document with words that are nearly impossible to comprehend for a layperson. As a result, policyholders are forced to make judgments based on insufficient or inaccurate information. Furthermore, misunderstandings while filling out a claim form and attaching documents to submit a reimbursement claim request can result in the claim being rejected or the claim amount being reduced. As a result, in order to prevent making an expensive error, you can call a claim specialist who will — answer all of your questions.

  • So that you don’t have to fight, begin preparing your claim form ahead of time.
  • Assist you in preparing your self-claim online.
  • We’ll walk you through the claim procedure step by step.
  • Determine which documents are appropriate. Resolve a TPA’s question and assist you in filing a grievance.

These pointers not only will make the claim process go more smoothly for you, but they will also help you get the claim pay-out you deserve.

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