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Insurers are relying on the coding increasingly and Insurance Information
Bureau (IIB), which is part of Insurance Regulatory and Development
Authority (IRDAI), has started an information bank where such information
that can be analyzed.
f) Processing of claim
A reading of the health insurance policy shows that while it is a commercial
contract, it involves medical terms that define when a claim is payable and
to what extent. The heart of claims processing in any insurance policy, is in
answering two key questions:
Is the claim payable under the policy?
If yes, what is the net payable amount?
Each of these questions requires understanding of a number of terms and
conditions of the policy issued as well as the rates agreed with the hospital
in case treatment has taken place at a network hospital.
Admissibility of a claim
For a health claim to be admissible the following conditions must be
satisfied.
i. The member hospitalized must be covered under the insurance policy
While this looks simple, we come across situations where the names (and in
more cases, the age) of the person covered and person hospitalized do not
match. This could be because of:
It is important to ensure that the person covered under the policy and the
person hospitalized is the same. This kind of fraud is very common in health
insurance.
ii. Admission of the patient within the period of insurance
iii. Hospital definition
The hospital where the person was admitted should be as per the definition
of “hospital or nursing home” under the policy otherwise the claim is not
payable.
iv. Domiciliary hospitalization
Some policies cover domiciliary hospitalization i.e. treatment taken at home
in India for a period exceeding 3 days for an ailment which normally requires
treatment at hospital/nursing home.
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