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The Insurance Times
Q. Why does an insurance company usually pay less than the hospital and doctor
bill that is submitted?
A. The insurers reduce the claim submitted for reasons, such as:
1. Excess amount
2. Coinsurance
3. Eligible expenses
4. Usual and customary charges
5. Exceeded benefit's maximum limits
Types of claim forms
There are two types of the Claim Forms, Primary and Secondary Claim Forms. Features
and usage of each are as follows:
Primary Claim Form
It is a form used for outpatient, emergency daycare and emergency inpatient treatments.
It is also used for pre-authorisation of treatment requests.
Pre-authorisation means the review and approval of services by the insurer prior to or
concurrent with the treatment date.
Secondary Claim Form
It is a form used for daycare and inpatient treatments (hospital admissions).
Dr. K. Raja Gopal Reddy
Phd, FIII, FCII(UK), FLMI (US)
Chartered Insurance Practitioner
Resident Editor, The Insurance Times
344 Guide for Health Insurance
