How Health Insurance Companies Approve or Reject Claims
Health insurance pays part of your medical bill when you become ill or injured. But before that, you have to file a claim with the insurance company. A claim is simply asking for money to cover your medical expenses. So, how do insurance companies determine if they should pay or not? Let us make it simple.
What Is a Health Insurance Claim?
A health insurance claim is a message you send to your insurance company that states, “Hello, I underwent a medical treatment. Will you pay for it?”
It can be made in two ways:
- Cashless claim – The hospital sends a message to your insurance company. If they agree, the company pays the hospital. You don’t need to pay much.
- Reimbursement claim – You prepay the hospital. You charge the insurance company later. They reimburse you if they accept.
Step 1: You Go to the Doctor or Hospital
First, you are attended by a hospital or doctor. In the event of an emergency condition, you may not be able to inform the health insurance companies beforehand. But if it is a scheduled surgery, you or the hospital needs to inform the company beforehand.
Step 2: Claim Is Sent
Then your treatment information is sent by the doctor or hospital to the insurance company. Or you send bills yourself if you paid for it in advance.
This involves:
- Your medical reports
- Doctor’s referral
- Hospital bills
- Identity proof
- Insurance policy details
Step 3: Claim Review Begins
The insurance company begins processing your claim now. A group of individuals examines your bills and reports. They need to know:
- Did you actually need the treatment?
- Was this covered in your policy?
- Did you send in all the proper documents?
- Are there errors?
- Here is where they make their decision: approve or deny.
Step 4: They Approve or Deny
After they check everything, the company makes a decision:
- Approved: If your treatment is included, and everything is okay, they approve your claim. They either pay the hospital or reimburse you.
- Rejected: If something is missing, wrong, or not included, they may deny your claim. They will also tell you why.
Common Causes of Rejection
It’s discouraging, but sometimes claims are turned down. These are a few of the reasons why:
- Missing documents – If your reports or bills are missing.
- Treatment not covered – Some insurances do not cover all forms of care.
- Waiting period – Some diseases are not covered during the first few months of your policy.
- Policy expired – If your coverage ended before treatment.
- Wrong information – If the facts you provided were not accurate or incorrect.
How Health Insurance Companies Approve or Reject Claim
Don’t panic! You can still take action:
- Phone the insurance company and question why it was rejected.
- Forward any outstanding documents.
- Compose an appeal (a formal letter asking them to recheck again).
- If that does not work, you can complain to the insurance ombudsman, someone who resolves these types of issues.
Tips to Get Your Claim Paid
- Read your policy well, know what is covered and what is not.
- Keep all your reports and bills safe.
- Notify the company immediately of a hospital visit.
- All the forms must be filled in properly.
- Ask the help desk of the hospital, and they will assist in making the claims.
Conclusion
Medical insurance is a big assistance when you are unwell. But to avail it effectively, you need to be aware of claims. Keep your documents in front of you and speak clearly to the medical company. In this way, you can avail the assistance that you require, with no stress.
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