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Navigating the claims process – How to claim for Medical Insurance

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Medical Insurance is meant to help you take care of your day-to-day medical expenses and help you financially. But claiming may be overwhelming because of its processes.

This piece will help you understand Medical Insurance better when it comes to claiming. From understanding the terminology in Medical Insurance to overcoming challenges, this guide will shed light on your questions and confusions with Medical Insurance claim procedures.

What is the Medical Insurance claim procedure?

There are no claims processes for most Medical Insurance providers. If you use the network providers at your disposal, claims will be paid to the provider through your cover. In most cases, you will need to have your membership card and your ID to the contracted network provider. They will then submit the claim on your behalf to the Medical Insurance provider. To ensure that claims are not rejected, you must ensure you understand your medical insurance coverage.


Understanding Your Medical Insurance Coverage

A Medical Insurance claim not being rejected is dependent on your understanding of your policy’s coverage. If you lack information on what your policy covers, you may face disappointment when your claim is rejected.

Here are some of the most important things you need to understand to avoid your claim being rejected:

Decoding Medical Insurance Terminology

You need to know how to decode Medical Insurance terms. Without understanding, you may face difficulties. Every provider is different, and the terms may slightly change from what you know.


Waiting period

Wating periods differ depending on the provider. Medical Insurance usually has a waiting period of 3 months but others have only a one-month period. If you have any medical expenses during this period, you will pay out-of-pocket. In terms of pre-existing conditions, some providers have a waiting period of up to 6 months.

This period is put in place to prevent members who join, claim, and cancel their policies.

Limits and exclusions

Limits and exclusions are one of the many reasons for a claim being rejected.
Limits refer to the extent of cover in certain benefits. Exclusions then refers to the list of services and conditions which are always excluded from cover.



Picture this scenario. You need to see a doctor and you find one within the network. Your claim would later be rejected because there was no pre-authorisation. This may be confusing because you already went to see a doctor a couple of times without any need for pre-authorisation.

Pre-authorisation works on some benefits after a certain number of getting that service.

The terms and conditions for pre-authorization are different for every provider. Some plans have specialists’ benefits, and these benefits require pre-authorization.

Some benefits cannot be covered without pre-authorization. That is why you need to know when and for what benefit, will you need to have pre-authorization before visiting a health provider.


Network doctors

Medical Insurance claims may also be rejected when you go to a doctor who is not a part of your provider’s network.

Most providers have navigation for different areas and the doctors on the network. It is important to check if a doctor you saw before is still part of the network. If it happens that there are no doctors in your area, some providers have options that include substituting seeing a doctor physically with virtual consultations.


Navigate the claim process- Seamlessly!

Medical Insurance claims processing steps shouldn’t bear disappointing results. If you understand your Medical Insurance coverage, you should not have to worry about any claim being rejected.

Not all Medical Insurance plans are the same and benefits as well as limitations may vary. Descriptions of benefits given are meant to be for general educational purposes only and you must ensure that you seek the advice of a broker to ensure any product choice you make suits your individual needs.

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