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Health Insurance Claim Procedures
 
(1) Health Insurance Claim Procedure   (2) Protect Your Interest
(3) Claim Form to be Sent to TPA   (4) Circumstances under which claims get Rejected
(5) Claims not Allowed - Some Case Studies   (6) Consumer Forum Cases in Health Insurance (Some Judgments)
1- Health Insurance Claim Procedure
The best way to protect your interests when you are dealing with Banks, Telephone Companies, Utility Companies is that your own records should be complete. At appropriate time when you are having any dispute with them, then you will have to prove that what was the payment plan agreed, when the payment was made, whatrefundable security deposit was given in the beginning.
The same rule applies with respect to Health Insurance to be purchased from an Insurance Company.
The steps you should follow are; Maintain systematic files in the following manner:
File 1. Maintain Insurance records file so that following documents are filed as and when received/sent;
Leaflet of Insurance Company from whom the policy is being purchased.
  1. Copy of filled up proposal form submitted to the Insurance Company.
  2. Receipt received from Insurance Company.
  3. Any correspondence received or sent to the Insurance Company.
  4. Any correspondence received or sent to the TPA.
  5. Photocopy of ID Card.
  6. Insurance policy received from Insurance Company.
In Addition to this :
File 2. Maintain proper Medical records file of every family member (separately) so that following documents are filed as and when received:All Prescriptions from Doctors/Medical Consultants,
  1. All Health check ups reports
  2. X Rays,
  3. All Pathological tests reports,
  4. Receipts of Doctors/bills from Chemists. 
If original documents are to be submitted to your office for reimbursement then photocopies of the same should be filed in this file. Whether today you decide to buy Health Insurance policy or not you should maintain this file (File 2) because of following reasons :
  • Even under normal conditions when you go to Doctor/Consultant for Consultation he finds the record of this file useful for diagnosis/line of treatment as he basis his treatment on seeing the past history, suitability of medicines, your allergies, proneness to side effects due to certain medicines.
  • After some time when you buy Health Insurance Policy and claim has to be lodged then these documents can be used as an argument to prove that in the past:No preexisting disease was diagnosed in the past.
    1. A specific preexisting disease was known when the policy is being taken and the degree of the disease is also knownUsefulness of File 2 is also very much relevant forthe following:
    2. If the Insured has to undergo hospitalization then all the medical expenses incurred 30 days prior to this date are also payable. (In caseof Cholamandalam this is 60 days)
In Case bills/receipts are taken and put in file then you can include these in the claim document being submit to TPA/insurance Company.
In the event of claim not being accepted in full
  • If the insured has to take up the matter with higher authorities in Insurance Company.
  • If the insured has to take up the matter with authorities like Consumer Forum then the whole case will be argued on the basis of these documents only.
Let us take an example :
Insurance Company /TPA takes stand that claim is disallowed as the insured had high BP and it was a preexisting disease.
Then Documents of earlier treatments even for viral fever, where a family Doctor had treated the insured can be used to prove that 2 years back or 1 month back on such and such date BP reading was taken by the doctor and it was normal.
Every document can assist you in proving your view point and getting the claim settled with the Insurance company to your satisfaction.
 
 
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