Health Insurance Claims

By: EconomyWatch Content   Date: 18 February 2010

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Learning the process of filing for health insurance claims helps to avoid any delay or financial set backs that may occur. Though, filing for claims is not a complex process, one can learn it in shorter time. Nevertheless, it requires precision and attention to details. The learning starts from the time the contract is handed over to you and you start identifying the medical conditions that are covered.

Health Insurance Claims at Two Levels

Most health insurance claims can be done at two levels:

Indemnity: This stage usually occurs once the medical assistance has been paid by the insured and he/she asks the insurance company to indemnify. This process remains simple with just a few forms and documents. If the claim is rejected at the first instance, it goes for a second appeal.

Requesting after rejection: Once the insurers have mailed the rejection letter with their reasons, study the clauses of the contract again. Look for any discrepancies. If you notice that there is some gap between what was said and the reason of rejection, communicate with the insurance company and resolve the matter immediately. Attach the policy documents and doctor’s bills with the request.

Pretext for Denying Health Insurance Claims

Health insurance companies make money through premiums and their investments. Remember, their basic instinct is to reject the claims and keep the money pool as big as possible. For the same reason, you may find a lot of conditions specified in the contract and this may call for immediate rejection of any claims.

 

Some of the conditions are mentioned below:

 

Payments history: Whether the premium was missed or none were paid during the time of treatment.

 

Eligibility of the patient: Whether the patient is an immediate family member or some one out side the purview of the coverage.

  • Eligibility of the treatment: Whether the kind of treatment undergone and is being claimed for is eligible for claims or not.
  • Validity of the process: Whether the right process was followed in dispensing care.
  • Pre-existing conditions: Whether the medical condition pursued for was pre-existing or a fall out of a pre-existing condition.

 

It is therefore advised by most people that the contract clauses must be read very closely before one plans to file for health insurance claims.


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