Page 257 - IC38 GENERAL INSURANCE

C. Documentation in health insurance claims

Health insurance claims require a range of documents for processing, as
explained earlier. Each document is expected to assist in answering the two key
questions – admissibility (Is it payable?) and extent of claim (how much?).

This section explains the need for and content of each of the documents
required to be submitted by the customers:

1. Discharge summary

Discharge summary can be termed as the most important document that is
required to process a health insurance claim. It details the complete
information about the condition of the patient and the line of treatment.

As per IRDAI Standardization Guidelines the contents of a standard Discharge
Summary are as follows:

1. Patient‟s Name
2. Telephone No / Mobile No
3. IPD No
4. Admission No
5. Treating Consultant/s Name, contact numbers and Department /

Specialty
6. Date of Admission with Time
7. Date of Discharge with Time
8. MLC No / FIR No
9. Provisional Diagnosis at the time of Admission
10. Final Diagnosis at the time of Discharge
11. ICD-10 code(s) or any other codes, as recommended by the

Authority, for Final diagnosis
12. Presenting Complaints with Duration and Reason for Admission
13. Summary of Presenting Illness
14. Key findings on physical examination at the time of admission
15. History of alcoholism, tobacco or substance abuse, if any
16. Significant Past Medical and Surgical History, if any
17. Family History if significant/relevant to diagnosis or treatment
18. Summary of key investigations during Hospitalization
19. Course in the Hospital including complications if any
20. Advice on Discharge
21. Name & Signature of treating Consultant/ Authorized Team

Doctor
22. Name & Signature of Patient / Attendant

A well written discharge summary helps the claim processing person immensely
to understand the illness / injury and the line of treatment, thereby speeding
up the process of settlement. Where the patient unfortunately does not survive,
the discharge summary is termed Death Summary in many hospitals.

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