A delayed insurance claim can occur for a number of reasons – delays in informing the insurer, submitting an incomplete claim form, delays from the insurer’s side, etc.
Overall, your insurer needs conclusive proof of what you say happened to move forward with your claim. Otherwise, you cannot get your claim settled.
Here are five main reasons why your health insurance claim can get delayed.
While filing medical insurance claims with your insurer, it is imperative that you disclose all necessary information in a factually correct manner. It is on the basis of this information that the insurer will investigate your claim to initiate your claim settlement process. Non-disclosure of accurate information can lead to delays in this process.
2. Not Filing a Claim on Time
One of the main reasons claim settlements are delayed is that policyholders are not able to submit a claim on time. Every policy has a deadline in its terms and conditions under which the claim should be filed.
It may differ between insurance providers, but generally, it is 24 - 48 hours for intimations and 15 days for submission of documents (reimbursement). Thus, it is vital to take time out of your day and get the claim proof done by the deadline to avoid any delays.
Some common reasons for delay in claim settlement process include:
Delay in information exchange between your insurer and the hospital.
Not following up with your insurer or the TPA regarding your claim.
Delay in submitting your discharge summary or other bills to your insurer.
In case of delays, you have to provide a valid reason for the delay in filing your medical insurance claim to ensure that your claim is settled.
3. Misplacing Required Documents
You must submit the necessary documents along with your completed claim form when filing your claim. If you misplace any one of these documents, your entire claim filing process will be delayed.
If you file your claim without adding all the necessary documents, your insurer will have difficulty approving it, which will delay the claim settlement process even further. This also applies to policy beneficiaries when applying for the death benefit/health insurance refund after death.
You must ensure that you provide all necessary documents to your insurer in accordance with the policy terms and conditions for an easy claim settlement.
4. Not Adhering to the Claims Process
Most insurers offer two settlement approaches: a cashless claim process and a reimbursement claim. The process for filing a claim in these two approaches is significantly different.
In the case of a cashless claim, you have to fill out the pre-authorisation form, while in the case of reimbursement, you have to provide documents to your insurer, including hospital payment receipts, hospital bills, medical bills and medical payment receipts.
If you make an error while submitting necessary documents or fill out the form incorrectly, your claim process will be delayed.
5. Submitting Incomplete Pre-Authorisation Form
When you claim cashless treatment from Reliance General Insurance, you have to submit your completed pre-authorisation form at least 48 hours before planned hospitalisation and within 24 hours of emergency hospitalisation.
The following are guidelines that you must follow so that your
health insurance claims process is settled quickly and seamlessly:
Obtain the pre-authorisation form from the insurer.
Ask for the claim form from the hospital's TPA desk and fill it out properly.
Ask your doctor to fill in the necessary details regarding the treatment.
Make sure the cost of treatment is sent to your insurer.
Submit the supporting documents and the duly-filled pre-authorisation form to your insurer.
Once the documents are submitted, your insurer will review them and move forward with the health insurance claim process. However, providing incorrect information in your pre-authorisation form can lead to a delay in settlement of the claim.
Delays in Insurance Claim Settlement From the Insurer’s Side – Exchange of Documents Between Hospital and Insurance Company
There could also be some delay in the claim process due to settlement issues between the hospital and the health insurance company.
The faster the bill arrives. The quicker the process of filing the claim will be.
What Happens if There is Delay in Health Insurance Claims?
Since the IRDAI is the final authority on insurance-related problems, according to its guidelines, the following turn of events can be expected in case your claim is delayed:
Your insurer may either reject or settle your claim within 30 days after receiving the last required document.
In case the claim payment is delayed beyond 45 days, your insurer will be liable to pay interest to you from the claim payment date at 2% above the bank rate.
You have the option to accelerate the claim process in case there is no known cause for delay. In such a case, you can:
Check the web portal of your insurer/TPA to ascertain what could be the possible cause for delay, and find a solution to the problem.
Send emails to your insurer’s claims team consistently to ask for updates on your claim process.
Continue maintaining communication with those involved in the claims process, including the TPA, surveyor, investigator and your insurance company.
If there is no resolution or response, approaching the Insurance Ombudsman is advised.
Tips to Avert Delayed Insurance Claim
Keep Necessary Documents Ready
Your documents should be in order before submission. They should include a filled pre-authorisation form or claim form (in case of reimbursement), valid identity proof, all original bills/receipts and the discharge card from the hospital, along with any other additional documents.
Check Policy Exclusions
Certain health policies come with exemptions that you must be aware of. Choose your coverage carefully, as your insurer will not provide financial protection for exclusions under the policy.
Know Your Sum Insured
Make sure you are aware of the sum insured limit, as any coverage above this limit will not be provided. You should choose the sum insured limit based on your medical requirements. Alternatively, you can opt for our Super Top-up Insurance in case you require financial assistance at a time like this.
Check for Policy Lapse
You cannot make a claim if your policy has lapsed. Keep an eye on the expiry date of your health policy and renew your policy before it lapses.
100%* Health Insurance Claims Settled by Reliance General Insurance
At Reliance General Insurance, we ensure that your
health insurance claim process is easy and fast. Getting in touch with us as quickly as hospitalisation takes place can help you obtain cashless treatment without any inconvenience.
In the case of financial reimbursement, you can file your claim within 15 days from the date of discharge, along with the necessary documents to settle the claim.
Our
health insurance plans are made to be affordable for you and your family. Each health plan is designed to help you manage your finances when faced with medical situations that may cause you to lose out on your life’s savings.
Conclusion
Following the policy conditions for submission of required documents and correctly filling out necessary forms can help you avoid any delays in insurance claim settlement. You can also seek help from Reliance General Insurance if you experience any difficulties while completing your claim process.
Frequently Asked Questions
What is the time frame for filing a claim on my health insurance?
The timeframe for filing a claim differs from one insurer to another. In case of reimbursement, you can generally raise a claim within 15 days after being discharged from the hospital.
What does the Claim Settlement Ratio mean?
Claim Settlement Ratio is the percentage of claims that an insurance company has successfully settled in a year.
