Health Insurance Claim Compensation
A health insurance contract is defined as a contract between the insurer and the insured wherein the insurer pays for a portion of the medical expenses in case one is unwell or gets hurt during an accident. A few of the health insurance contract also allow for a certain payment of medical expenses towards vaccination so that one does not get sick. The amount of payment that an individual pays from one's pocket when visiting a doctor is called co-pay. Suppose an individual visits a doctor and the total medical expenses are USD 100. As per the terms of the health insurance policy, co-pay is 25% which implies that the individual is expected to pay 25% i.e. USD 25 in this case. The doctor receives an amount of USD 25 from the individual and presents a claim of 75 USD to the insurers of the particular individual.
The actual process of the insurance claim begins no sooner than one takes an appointment from the doctor. The doctor furnishes all the information about the insured to the claim processing centre of the insurance company.
When an individual arrives at the doctor's facility, he is expected to fill in a number of forms with the necessary insurance information and provide one's insurance card to the doctor's attendant. The moment an individual pays the co-pay amount to the doctor and his visit to the doctor's clinic is complete; the claim process settlement for the remaining medical fee of USD 75 is lodged by the doctor on the insurance company. As long as the diagnosis and treatment of an individual is for an illness covered under the policy, the insurance claim lodged by the doctor on the insurance company is likely to be paid. In case the individual's illness is beyond the scope of coverage of the health insurance plan or in case the full amount of 75USD is not paid by the insurance company to the doctor, the amount stands recoverable from the individual.
There are a number of reasons as to why the insurance company denies the insurance bill presented by the doctor. The rejection of claim could be on account of medical procedure not being covered by the insurance plan, medicinal supplies made by the doctor not covered under the plan or even in cases where the insurance company is of the view that the medical procedure done was not necessary.
An individual should take few simple and easy steps to ensure that the claim does not get rejected. These include a thorough review of the insurance policy by the individual to understand that the treatment is covered in the plan. Preferably the treatment sought from the doctor should be done after the necessary authorization from the insurance company. The claim must be filed properly and no information should be missing. Needless to say that the claim has to be filed within time limits. A department of insurance is attached to each and every state of United States to protect the interest of the consumers as well as regulating the claim compensation methodology adopted by the insurance companies.