How to Claim From Your Health Insurance – Simples Steps to Follow
Insurance claims can be a tiring process. With piles of insurance jargon thrown into pages of claim forms and receipts, it can be exhausting to get your money back. We break down what you need to do in order to get your claims in the quickest and simplest way possible.
Know Your Jargon
Begin your process by learning the policy terms that affect your coverage and claims. Even if you are not submitting a claim, it would be wise to just read through your current insurance policy and understand what it entitles you to.
These are what you pay for your insurance. It could be a one-off payment or a recurring payment by month, quarter or year. Ensure you are able to afford your premium consistently. Failure to pay will cause a lapse in policy, resulting in you losing coverage.
A deductible is an amount you have to pay for your medical expenses before your health insurance makes a payout. You usually only need to pay the deductible once a year. So for e.g. If your deductible is $1000, it means every year, your bills have to go past $1000 before your insurance claims can be applied. If you have a $10,000 hospital bill, you will pay the first $1000, and the remainder $9000 will be claimable based on your policy.
Co-insurance is a percentage of the bill you have to pay after your deductibles are met. So if you have a $10,000 bill with a $1000 deductible and 10% co-insurance, then you will pay $1000 (deductible) + $900 (10% of $9000 remaining) = $1900 of $10,000.
These are limits to what you can claim from a policy.
Policy Exclusions are situations where benefits will not be paid. Most commonly, pre-existing illnesses or conditions are excluded from health insurance. Exclusions will vary, do read through what your policy will or will not cover before purchasing or proceeding with a claim.
This is the period before the policy will come into effect from the time you bought the insurance. The waiting period usually goes from 30 to 90 days. During this time, no benefits will be paid for any bills.
This is the time limit where benefits will only be given after you have been sick or disabled for more than a set number of days.
Most policies renew as long as you pay your premiums, however, the insurer may still change the premium and benefits. Ensure you are always on top of it. Some policies only cover a limited time period based on a condition, like staff medical benefits that only cover you as long as you are under the company.
This is the period from the date of policy purchase. They usually last 14 to 21 days. During this time, you are able to cancel the policy at any time and receive no penalty. You will be refunded of all expenses.
A typical insurance claim will go through a 5-step process.
1. Notifying Your Insurer
If you have an on-going policy, it would be preferable to notify your insurers before your appointment or medical visit. This will help to keep your claims within the time limit, as some insurers have a cut-off period after the date of treatment. If you do not notify your insurer in time, your claims could be rejected.
2. Pay Your Bills
Once your treatment is done, ensure you have paid all the bills including your deductibles and co-insurance based on your policy.
3. Obtaining Documents for Claim Submission
The most important step in the claim process, ensure you have all documents required before beginning your claim submission. This will cut unnecessary time required to compile your data for the forms. This includes everything from receipts, prescription letters, lists of medications given, bills and doctor’s notes. Go through what your insurer would require and call them up if necessary. You don’t want to be rejected because of your lack of homework. Once everything is in order, get the insurance claim form and fill it up with all the information you have.
4. Submitting Documents to Your Insurer
After you have arranged all the appropriate documents, submit them to your insurer. Check the different methods your insurer allows for submission. Usually, you are able to directly mail them, deliver to them in person, or submit online via their website.
5. Stay Updated
Even with due diligence on your part, some hiccups may still occur. After submitting your documents, you will want to contact your agent or insurer to liaise about the status of your submission. Keep in mind that most claims take weeks to process and will require patience on your end. Check in with your insurer once in a while to ensure things are still moving along.
What If Your Claims Are Denied?
First off, ensure that your claims are actually denied and not rejected. Rejected claims are not processed due to either lack of information or misinformation. You would not need to appeal or fight for such claims. Find out why the claim was rejected, get the required information and resubmit. Denied claims, however, are when the company has processed the claim and decided not to cover it.
A claim could be denied for many reasons, the most common being:
- The plan does not cover what you are claiming for.
- Exceeded plan coverage.
- The service provider is not within the insurer network.
If your claim was denied due to a policy rule, it is unlikely you will get any compensation. If however, you feel your denial was inappropriate, do check the time period where you will be able to submit your appeal. The letter of denial should state when and how you can appeal for your claim.
How to Write an Appeal Letter
An appeal letter should be kept as simple and understandable as possible. Even though a claim denial could cause anger and frustration, try and leave that out of your letter. The person receiving it probably has to sit through tons of such letters every day, and it would be harder to sift out the information among the hate.
- Supply key information like, why are you writing for, who you are, the case number and why your case was denied.
- Explain why you think the denial was incorrect, back up with any other information that could be useful.
- Provide any supporting documentation that would prove your claim was justified. Your doctor could help you write a letter to attach to your appeal.
- Remember the time period given for the appeal and submit before!
We hope you do not have to go through such tedium for your insurance claims, but if you did, we hope you got your claim!