Page 337 - Ebook health insurance IC27

Sashi Publications

1. Submission of claim
A claim could be submitted either by the insured person, his agent or directly by the
provider itself for reimbursement of expenses incurred for services covered under the
policy.

The provider could be a hospital, a pharmacy, a laboratory, clinic or a diagnostic center.
Claims are usually to be submitted within a time frame, mentioned in the contract of
insurance (usually 2 months). Delays in submission of a claim without valid justification
may result in the eventual decline of the claim.

2. Acknowledgment of claim receipt
All receipts of claims received by an insurance company should be acknowledged.
Acknowledgment not only creates a sense of security for the member, it also offers a
valid support in the event of any legal dispute.

3. Batch creation of the received claim
A claim that has been acknowledged should be given identification for easy retrieval and
tracking. Identifications are given in the form of numbers, names, batches, etc.

4. Auditing the claim
This is a process where the claim is reviewed by medically qualified and experienced
personnel to verify the eligibility of the claim.

A medically qualified person is usually is a doctor, qualified nurse, pharmacist or a
paramedical technician with considerable experience both in the field of medicine and
also in the field of insurance services.

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