Back in the day, the insurance industry had gained a notoriety of not paying out on claims. It was said that once an accident or incident happened, the insurance companies would try their best not to honor the claim. This has over the years hindered uptake of insurance in the country as many people believe that there is a high likelihood that their claims will not be honored. However, this perception is changing for the better as people come to the realization that most of insurance companies do honor their claims and in a timely manner.
In this article, I will endeavor to demystify the health insurance claim process at APA so that one can be able to know what to do and which documents to present to make a claim.
Health insurance covers the risk of a person incurring medical expenses. It is basically a contract between you and insurance company that states that they will cover your medical expenses should you get sick or have an accident. The contract also specifies the amount that they can pay and the circumstances under which they can pay.
In health insurance one can either be an out-patient which means one is treated at the hospital and goes home or an in-patient where one is admitted for observation or a procedure. I will look at the claim processes for the two categories.
When you get to the hospital, there is a form one is supposed to fill out indicating your personal details, the scheme you are under incase the insurance is provided by the employer and your membership number.
This form is later filled by the doctor after seeing you and indicates the diagnosis and tests carried out if any.
This form is thereafter sent to the insurance company and the claims are paid within 30 days if all the documents are in order. However, if there are some documents missing or maybe a doctor did not write a diagnosis or sign the claim form. The same will be sent back to the hospital for correction.
However, for dental and optical covers, the hospital must seek pre-approval from the insurance company before attending to the patient. This is because policies have different limits for the same.
A claim can be rejected when a hospital undertakes a procedure that is not covered in the policy. This can be for example a pregnancy related procedure when one is not covered for maternity. In such a scenario, the individual would be asked to settle the bill. However, APA Insurance usually send a policy document to the hospitals showing what is covered under the various policies to avoid such scenarios.
This is basically where a patient has to be admitted either for a procedure or for observation.
When you get to the hospital, you have to fill out a claim form after which the doctor has to indicate his diagnosis and also sign.
Just like the optical/dental covers, the hospital has to seek pre-approval. The is because different schemes/policies have different bed limits. It is at this point that the insurance provider gives a limit as to how much a member can be able to spend at the hospital. This depends on the treatment/procedure to be carried out.
It is at this point that the insurance company issues the hospital with a letter of undertaking guaranteeing that they will cover the medical expenses. They also issue a discharge slip allowing the patient to be discharged from hospital once they have recovered.
If after admission a member has exhausted their cover, APA usually notifies the employer if one is under a scheme who undertakes to pay the excess. This amount is thereafter recovered from the employee.
In the case of an individual, one can come to an agreement with APA that they cover the excess. Thereafter the member is expected to pay the amount as per the agreement. In some cases, the APA even pays the excess and does not demand for refund from the client in say a situation where a client is unable to raise the amount. How awesome is that!!!
What really stood out for me in regard to the settling of claims arising from medical expenses is that;
Claims by health providers are paid up in 30 days. In the past I have come across complaints by some hospitals that some insurance providers take months to pay for bills and this has led to some hospitals blacklisting some of these insurance companies. This has happened to me in the past and it caused a lot of inconvenience.
APA usually negotiates prices with hospitals meaning that you get services at a cheaper rate. This has an effect of enabling your cover limit to last longer.
They send quarterly reports on your usage of the medical cover. This helps one track their expenditure and also help you detect anomalies in the hospital billing in time.
In the event that you exhaust your cover while you are at the hospital, they can pay the excess for you and thereafter you can come to an agreement as to how you will refund the money.At APA Insurance, they got out of their way to ensure that the claim process is as smooth as possible enabling you to have peace of mind. If you have an query on the claim process or would just like to know more about the APA Insurance products, click here.