Health care claims tutorial

Healthcare claims cover the risk of sickness and offer the benefits given on the event of hospitalization, surgery, occurrence of illness etc. The benefits which can be claimed under healthcare products are:

a) Outpatient or General Practitioners care – General Practitioners (GP) cater to the primary care benefits of the patients and if there is any specialist treatment required then the general practitioner can refer the patient to a specialist doctor/hospital.

b) Inpatient or Hospitalization including surgery - GP or the Specialist may refer the insured to an approved hospital. The hospital care includes in-patient treatment and day surgery in the hospital.

c) Dental will cover the dental benefits like capping, polishing, crowning etc

d) Maternity will cover the benefits including surgery, miscarriage etc.

Depending on the type of health insurance which has been taken, the insured can select the benefits he wants to be covered for. There are some health care products which cater to special illness such as cancer, kidney operations. There also some schemes by which the insurance companies seek to provide benefits to their customers. One such scheme is the Panel doctors/hospitals concept. A network of General Practitioners, Specialists, clinics etc can be grouped by the Insurance Company to form a “Panel of Doctors/hospitals”. So, there are a range of medical products offered by Insurance companies which provide ease of payment for the insured if he/she visits panel doctor/hospitals. This range of products will be similar to the standard health care products like except that the hospital payment can be done by cashless cards and later the hospitals will reimburse the amount from the Insurance Company. There are also other benefits which are associated with such schemes.

The insured should be well aware of his covered benefits and his insured period (i.e. the time in which he will be covered, normally the healthcare products are renewable after one year). Generally the claims procedure in any insurance company for health care products is as follows:

The insured (client who has taken insurance) on the occurrence of an event (such as illness) can either approach the insurance company directly or the hospital will do it on his behalf in case of cashless reimbursement. On receiving the bills and the claim form from the hospital/insured, the claims executive in the insurance company will evaluate the details and check the eligibility of the claimant (insured) who has made the claim. The Claimant can be the insured himself or his dependants. The eligibility is needed to be checked in case there is a claim for benefits for which he may not be applicable for depending on the benefits terms and conditions. Once the claims executive has verified the eligibility of the claimant the claims will be processed and the payout amount will be calculated depending on the amount he is eligible for and the amount he has incurred (billed amount). After the processing, the payout amount will be forwarded to the Finance/Accounts department for the final payout via the chosen payment method (can be cheque, draft or bank transfer)

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