There are two getting a claim under a health insurance policy in Indonesia:
1. Cashless Hospitalization
2. Non-cashless Hospitalization
In couple of Cashless/planned Hospitalization
1. In few planned hospitalization inform your third Party Administrator/insurance company on the date of admission throughout the hospital quoting your contain number and health ID card anyway 4-5 days in growth.
2. The form for intimation to Third party Administrator and obtaining the history authorization for cashless claims services are sold with the admission counter on their hospitals.
3. The patient must software the form carefully just like any incorrect information may cause rejection of previous consent.
4. The medical condition associated with patient or the advantages of any surgical procedure is filled up by the doctor on a patient. Be sure 's your doctor is briefed correctly on the patient's history, otherwise this particular again lead to being rejected of previous authorization by Neutral Administrator.
5. In few new policies all brand-new existing diseases are omitted. At the time associated with signing previous authorization form ensure doctor has not supported anything about condition which can lead to assume it for decided previously.
6. The chock-full form is then sent out by the hospital authorities to the respective Look at Administrator of the players for granting of prior authorization of amount in hospitalization.
7. The Third Party Administrator carefully scrutinizes issue such as policy volume, validity of policy, Levels assured, waiting period, preexisting diseases etc promptly after being satisfied sends system authorization of amount directly to the hospital.
8. After satisfying itself the next Party Administrator will issue a prior authorization letter/ guarantee of payment letter into your hospital/Nursing Home mentioning the the quantity guaranteed as payable much more ailment for which someone is seeking to be admitted correct into a patient.
9. The Third Party Administrator has the legal right to deny the previous authorization if he is not satisfied with the documentation.
10. Unless the Third party Administrator gives the in advance of authorization letter to hospital, the hospital will not go about it as cashless claim. So the insured must vigorously follow-up using only the Third Party Administrator thanks to giving the authorization file.
11. If the letter from Neutral Administrator is not received or basically deny then the insured must first spend on the expenses from his pocket and then lodge a claim to the Third Party Administrator/insurance start.
12. In case of planned hospitalization they allow you to get previous authorization considering that insured has ample time to followup with the 3rd party Administrator. The problem offered emergency hospitalization.
Here my time is of essence. Hospital will not start liberation unless he receives authorization from 3rd party Administrator or cash on the insured.
13. This creates a panic situation and several times the insured are forced to pay from their
pocket and claim the amount from Self-sufficient Administrator/Insurance Company in normal course simply because of emergency. In many cases it has been seen that Third Party Administrator's delay the entire process of authorization so that shoppers pays from his pocket and then claims reimbursement.
14. Generally the Third Firm Administrator's grant authorization for your amount. If the cost in the treatment exceeds that amount an individual must give it from his signature pocket and then claim reimbursement on the inside Insurance company frauds within the policy polices.
In case of Non-Cashless Hospitalization/Emergency Hospital:
In case of Not for cashless Hospitalization the safe and sound must give preliminary intimation of their claim within 7 times of hospitalization (The intimation period will vary from company to company) in to the Third Party Administrator/Insurance Business'.
The notice would own following: -
1. Particulars produced by Policy number
2. Health NAME AND EXPERTISE card number and copy
3. Logo design of Insured Person
4. Address
5. Logo design of attending doctor
6. Logo design of Hospital
7. Nature of illness/injury
After fundamental insured is discharged the finale claim must appear on the company within week from the date from you discharge. The period of intimation differ in insurance companies.
The following documents must be attached considering the prescribed claim form of yours company: -
1. Original prescription of Doctor
2. Prescription of numerous doctor advising for hospitalization/tests.
3. Original reports of all diagnostic tests considering the original bills like X-rays, ECG, Import, MRI, Pathology etc.,
4. Detailed itemized bill the actual hospital for bed bids, OT charges, medicines, and details of any other charges if for example the hospitals have levied.
5. Surgeons certificate stating nature of operation deal with bill.
6. All bills for medicine purchased in the previous 30 days before hospitalization and
after discharge.
7. Hospital Receipts / bills / cash memos in Original (Copies of fee slips if payment is designed by credit card) duly stamped.
8. Discharge cert from hospital
9. Certificate from the doctor that the patient is fully cured and will resume his work
10. In case of domiciliary hospitalization a account from qualified nurse who attended someone in his residence sustained by a certificate from medical professionsal.
11. Copy of current insurance cover and previous policy.
12. C. I. R. in the case of problem and English translation of the same, if in any flip language.
13. The claim form had to be filled correctly and there should be no overlapping of information otherwise it bring about rejection of claim.
14. Since all the original documents are submitted considering the claim form the policyholder must keep a copy of the claim form and all of the the original documents submitted every thing claim form. At the time from you submitting the claim form she must obtain an acknowledgment on the inside insurance company about the receipt of the documents to serve obtain proof of submission.
15. The policyholder must followup pores and skin insurance company about your skin layer status of the claim as time passes as the insurance company require some other documents or clarifications the actual hospital about the fees.
16. The insurance company if finds everything in order shall make payment for the claim. Many times it deducts a great number amounts from the bill that are not authorized under the policy or which apparently be in excess.
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