One of the main ideas behind taking a health insurance policy is not having to pay from your own pocket for any medical treatment and to have all bills settled in a cashless manner. And almost all health insurance companies offer cashless settlement of hospitalisation bill claims. The process for making such claims is not that complicated. However, you need to follow a few key set of steps to make the claim settlement smooth.

From choosing a convenient network hospital well ahead of admission to being aware of some key insurance clauses and exclusions, you must be well-informed on important policy intricacies. Here are some key pointers for an easy settlement experience.

Zero in on a nearby network hospital

All insurance companies have tie-ups with hospitals all over the country. You must go through your medical insurance policy and find out the location of a network hospital near your place of residence, more so if the hospitalisation is planned. The list is updated by insurance companies on their websites, and so you must check the details regularly.  

Network hospitals are empanelled with your insurer for cashless service. The insurer settles the bill directly with the hospital. Cashless settlement means you would have to pay nothing or at best a small amount from your own pocket. Going for a network hospital nearby ensures that your commute to and from the hospital will not be tiring.

Inform the insurer or TPA early

If the course of medical treatment for any ailment is already decided – if it is a case of planned hospitalisation – inform the insurance company or the third-party administrator (TPA) about your treatment. Do this a week before you plan to get admitted. Send the relevant medical documents and doctor prescriptions to the TPA via email and also inform via the call centre if possible. The hospital’s insurance desk would also help you in such matters.

Get a consent letter for cashless settlement from the TPA or insurer. You must submit this letter at the hospital admission desk before proceeding for treatment. In case of an emergency admission, you must inform the insurer or TPA within 24 hours of getting the patient admitted or ask your family member or friend to do so if you happen to be the patient.

Take note of room rent caps

Many health insurance covers come with limits on hospital room rents. The rate of capping could be an absolute figure, say ₹5,000 per day, or a percentage of sum assured, usually 1 percent. Public-sector insurers such as United India Insurance and New India Assurance have such ceilings on room rents. So, if you get admitted in a hospital that charges a higher amount for the room, you may have to pay the remaining sum from your pocket. Also, a policy with room rent ceiling means that all bills are pegged to the room rent. So, if instead of ₹5,000 that you are allowed, you choose to get admitted in a hospital that charges ₹6,000, or 20 per cent more, your total bill settlement allowed would also come down by that proportion.

But if you buy a policy without any rent ceiling, you have nothing to worry about.

Be aware of exclusions and co-pay clauses

The insurance company may not pay for use of disposables or consumables (gloves, cotton, syringes, masks, sanitisers, etc.) during the treatment. Other charges such as extra room services availed by the patient are also not covered. Any registration, administrative or service charges are not covered, so are luxury taxes. These are apart from not paying for a host of medical and pre-existing conditions. Some insurers such as Care Health Insurance, Max Bupa, Digit Insurance and Tata AIG offer consumables riders with their health insurance that cover such costs.

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Then, there is the co-pay clause, wherein you need to pay a portion of the bill for certain medical treatments, according to the conditions set out in the insurance policy. Be aware of the amounts and stay prepared.

Carry all identity proofs and policy documents

You must carry the card that your insurer would have issued. Take the policy document also, just in case. Do not forget your PAN and Aadhaar cards, as also any other address proof. Medical documents and diagnostic reports, apart from the above-mentioned proofs, would be needed during admission. You must make a habit of carrying your insurance medical card with you whenever you travel. In case of an emergency, it will help your friends or colleagues to get you admitted quickly.