Health Insurance: How to make claim request if an insured person dies in hospital

The rising costs of treatment have made taking health insurance cover an absolute necessity. Ever since the outbreak of the Covid-19 pandemic, the demand for health insurance has increased many fold.

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With the surge in the number of Covid positive cases, hospitalisation and death during the second wave of the pandemic, the obvious question comes to mind if a health insurance claim is admissible if an insured person dies in hospital.

One of the basic eligibility requirements related to health insurance claims is at least 24 hours of hospitalisation. So, an insurance claim becomes admissible if an insured person remains hospitalised for more than 24 hours after getting admitted or dies in hospital after 24 hours of admission.

But how to make a claim request once an insured person dies in hospital?

“In case of the death of an insured, payable medical expenses per the insured’s policy terms and conditions will be settled by the insurer,” says T A Ramaligam, Chief Technical Officer, Bajaj Allianz General Insurance.

“There are two facilities that one can opt for while filing for Health Insurance Claims, i.e. Cashless Claims and Reimbursement Claims,” he explains.

Cashless Claims

If the customer chooses a network hospital of the insurer for a medical treatment, then cashless claims can be opted by the insured. The customer needs to flash his health ID card at the Insurance/ TPA desk to avail the cashless facility at the empaneled hospital. The process is then initiated between the hospital & the insurer where the customer is kept informed on the progress at every stage and the decision on the request received. Highest priority is accorded to the COVID – 19 cases.

Cashless Claim Process

1. In case the hospital admission is planned, customers should approach the insurance desk of the hospital which guides them in a cashless facility. The insurance desk forwards the entire case with pre-authorisation application form (which is countersigned by the treating doctor) to the insurer. Basis the case details and policy T&C, insurer approves the cashless facility. Generally, this approval should be taken 4 – 7 days prior to the treatment.

2. If you connect with your insurance company, they will inform you about the documents that may be required. Post sharing these documents and medical details with the insurer through the insurance desk, it evaluates the treatment details as per policy terms and conditions and informs the concerned hospital and insured.

3. The customer needs to produce following documents at the network hospital in addition to the documents that are specified by the insurer:-

a.i. Pre-Authorisation Letter (completed by insurance desk)

a.ii. ID card issued by the insurance company or Health Insurance Policy

a.iii. Aadhar Card, Pan card / Form 60 (For KYC purpose)

4. Once the treatment is done and the customer has availed the cashless facility, the original bills and treatment evidence should be left with the hospital. The hospital shares these bills with your insurance company and accordingly payment is processed by the insurer to the hospital.

5. In case of any unplanned or emergency medical treatment, the policyholder can simply contact the insurer through its customer care center or chatbot facilities to know about the empaneled hospitals. Once at the hospital, the customer can request for cashless hospitalisation by producing the insurance card provided by the insurers along with the policy copy to the insurance desk.

6. Once the customer makes this request, the hospital connects with the insurance company by filing the pre-authorisation request form and consequently the insurer issues an authorisation letter to the hospital. Insurer also shares details pertaining to the policy coverage of the customer.

7. Once the treatment is over, the insurer will then settle the payment of admissible claims.

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Reimbursement Claims

If the customer chooses a hospital which is not empaneled with the insurer, then the claim is settled on a Reimbursement basis. On receipt of the complete set of documents as requested by the insurer, reimbursement claims are settled typically within 5 days. For example, Bajaj Allianz General Insurance has launched a unique facility wherein customers can now instantaneously submit digital documents through the company’s self-service mobile application – ‘Caringly yours’ for assessment and settlement. Through this new facility, a health insurance customer can now receive their claims within 5 working days.

Reimbursement Claims Process

1. The insured can download the claim forms required from the insurance company’s website or can be collected from any of the offices/intermediaries of the insurer.

2. The customer is required to provide necessary documents along with the original medical bills to the insurer at the time of claim filing. These documents typically include a claim form, bank details, ID cards, hospital discharge summary, investigation and diagnosis reports and bills, original hospital and pharmacy bills along with paid receipts and prescriptions. Additionally in case of an accidental hospitalisation, a copy of FIR may also need to be shared with the insurer.

3. The insurance company evaluates the claim basis of the documents after confirming the T&C under the policy.

4. Post the evaluation the insurance company makes the payment to the beneficiary as per policy terms.

5. On non-receipt of certain mandatory documents, the insurer can ask for these additional documents to take a decision on the claim.

6. In case of claim repudiation, the insurer provides the grounds on which the claim is non payable.

“We have enabled digital mode for claim submission in our Caringly Yours App, Website & Portals for the ease of our customers which can be accessed from the comfort of their homes. All that needs to be done is click the pictures of claim documents and follow the prescribed guideline for submission. This also provides real time assistance to the customers through various communication channels such as Contact Centre, WhatsApp, Educational Videos etc,” says Ramaligam.