Page 239 - IC38 GENERAL INSURANCE

settlement of claims, organizing health insurance claims department is a
significant challenge.

Typically health insurance policies written in India cover hospitalization
anywhere within the country. The team handling claims must understand the
practices across the country to be able to appreciate the claim presented.

The health claims manager meets these challenges using expertise, experience
and various tools available to him.

In the final analysis, health insurance offers the satisfaction of having assisted a
person who is in need and is undergoing the physical and emotional stress of
illness of himself or his family.

Efficient claims management ensures that right claim is paid to right person
at the right time.

2. Claim process in health insurance

A claim may be serviced either by the insurance company itself or through the
services of a Third Party Administrator (TPA) authorized by the insurance
company.

From the time a claim is made known to the insurer / TPA to the time the
payment is made as per the policy terms, the health claim passes through a set
of well-defined steps, each having its own relevance.

The processes detailed below are in specific reference to health insurance
(hospitalization) indemnity products which form the major part of health
insurance business.

The general process and supporting documents for a claim under fixed benefit
product or critical illness or daily cash product etc. would be quite similar,
except for the fact that such products may not come with cashless facility.

The claim under an indemnity policy could be a:

a) Cashless claim

The customer does not pay the expenses at the time of admission or
treatment. The network hospital provides the services based on a pre-
approval from the insurer/TPA and later submits the documents to the
insurer/TPA for settlement of the claim.

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