Wednesday, 6 March 2019

A to Z About Health Insurance Claim

Posted by MyInvestmentsPub
(Published on 07-Mar-2019)

We are living in expensive times with escalating healthcare costs. Hence, buying a health insurance plan is a key component of financial planning, which provides protection against rising expenses arising from unforeseen medical conditions. This safeguards one from dipping into one’s savings to pay for sudden medical expenses. A health insurance policy pays for varied medical expenses including hospitalization, room rent, surgical procedures, nursing expenses, doctors' fees, cost of medicines and diagnostic tests. One can opt for a plan for oneself or/ and for one’s family.

In this article, we shall try and understand about medical insurance, mistakes to be avoided while filing claims, the claims process and benefits of opting for medical insurance.

What is health insurance and Claims?

A health insurance policy provides health cover for certain predefined medical conditions to the policyholder in return for regular premium payments by the insured. In the event of the occurrence of a medical illness, the amount can be claimed as a financial benefit for treatment expenses from the insurance company. A health insurance claim is a payment request submitted by the insured or the insured’s health care provider to the insurer for services or goods covered in the health policy. Once the claim is reviewed, the amount is disbursed to the requesting party on approval of claim. One can select an affordable health plan by computing the maximum premiums that one can pay with the help of a health insurance premium calculator. However, there are certain mistakes that should be avoided while filing a claim, else it can result in reduction of the settlement amount or even rejection. They are as follows: 

Mistakes To Be Avoided While Filing a Claim

1. Inaccuracy of patient’s information: Mistakes while filling the claim form like incomplete patient’s name, date of birth, missing out the group code or diagnosis description, etc. can lead to delayed payments and reduction in the claim amount disbursed.

2. Inclusion of excluded procedures: One can claim only for the surgical procedures covered in the policy terms and conditions. Several insurance companies exclude surgeries like infertility treatments or dental care. 

3. Poor documentation: This occurs when the service provider has documented incomplete or incorrect details of the medical procedures, which can lead to difficulty in claim settlement.
4. Upcoding or unbundling: This pertains to inaccuracy in recording the accurate level of service provided. This may be due to an error or an intentional attempt to over-claim reimbursement.
Upcoding: Codes entered for services a patient did not receive or more intensive procedures are recorded.
Unbundling: Billing for procedures separately, which are to be clubbed.
5. Duplicate billing: A claim filed for the same procedure or treatment, multiple times or inclusion of a test that was cancelled.
6. Other reasons: Failure to adhere to pre-authorization terms, billing mistakes, etc.

Chart audits help reduce the occurrence of such inaccuracies and increase claim payments. Also, one must select a good insurance company with a successful track record of quick claim approval and speedy settlement.

Claims process: 

Heath insurance claims can be undertaken in the following manner:

1. Cashless basis: The pre-condition is that the treatment is to be carried out in a network hospital of the Third-party administrator (TPA) servicing the policy. Each TPA issues a set of forms and guidelines that have to be complied with, to avail the monetary claim.

2. Reimbursement basis: The claim settlement can be availed by reimbursement of eligible expenses, subject to satisfying the preconditions and submission of relevant documents, namely claim form, discharge summary, prescriptions and bills.


It is important to inflation-proof one’s medical insurance as medical costs continue to soar, owing to limited availability of quality healthcare and growing demand for premium healthcare. Hence, opting for adequate health cover for oneself and one’s family is vital.


The importance of health insurance plans can't be overemphasized, however, it's also important to create an emergency corpus as a backup to aid in any sudden medical expenses. When it comes to you and your family’s health, it is always better to be safe than sorry.


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