Page 338 - Ebook health insurance IC27

The Insurance Times

Claims are verified by such staff for the following reasons:
(a) Eligibility of the claim medically. In this stage, the services provided are verified for

its medical eligibility. Verification is usually done with the data provided against the
usual and customary charges. For example, a claim submitted with the diagnosis
mentioned as headache, while the medications prescribed are routinely given for
heart ailments. Under this situation, the claim would not be medically eligible for
payment.

(b) Eligibility of the claim is respect to the policy terms. In this stage, the eligibility of the
claim with respect to the member verification, submission time, etc are checked.
For example, a claim submitted after the submission period mentioned in the policy
wordings will not be eligible for payment, unless valid justifications for the same are
provided.

(c) Eligibility of the claim in respect to the benefits and exclusions. In this stage, the
claim is verified against the benefits of the member's policy as described in his table
of benefits. All conditions not mentioned in his table of benefits would be excluded.
For example, claim submitted for a maternity event, if not mentioned in the table of
benefits, is then classified as exclusion. Or a claim submitted for a dental care if
mentioned in his table of benefits will be classified as a benefit and qualifies for the
claim to be settled.

(d) Eligibility of the claim in terms of annual overall limits and sub-limits. In this stage,
the payable claim is verified against the annual overall benefit and sub-limit for that
benefit and only claims with adequate benefit balance will be settled. For example,
a claim of Rs. 600 submitted for a delivery. While reviewing the claim, it was noticed
that the member had a benefit balance of Rs. 400 only as most of the benefit had

342 Guide for Health Insurance