Our Top Tips for Health Insurance Claiming.

In a nutshell, a health insurance policy provides financial protection against planned or unplanned medical expenditure, giving real peace of mind that should medical treatment be needed the cost will be covered. Resulting, reassuringly, in one less thing to worry about at what can be a difficult and stressful time.

However, like any insurance policy, terms and conditions apply.

Every day at JW Seagon we support lots of our clients through the claiming process. With over 90 years of combined health insurance claiming experience between them, members of the JWS team are expert at navigating through the various insurer claims processes. They can advise on what is required and handle claims on your behalf so you can focus on your recovery.

Whether you choose to use JWS to handle your claim, or deal with your insurer directly, here are some TOP TIPS from the team of things to do, and not do, for a smooth claims experience.

Don’t delay informing the insurer.

As most insurers have a time limit for making claims, it’s best practice to submit claims for reimbursement as soon as you have had your treatment.
For planned hospital admissions, the insurer needs to be informed in advance, whether directly or through us, to ensure the treatment is covered by the policy and that the cost will be met. Doing so is a condition of many policies and not complying could incur a penalty.

In case of an emergency admission to hospital, the insurer must be informed as soon as possible so they can liaise directly with the medical facility to ensure the costs of treatment are settled.

And if we know you are in hospital for the delivery of a baby, we can tell you how to enrol the baby from the date of birth, and this typically needs to be done within the first 30 days.

Before seeking treatment, know your policy.

If you haven’t used your policy before, or have only done so rarely, remind yourself what your policy includes. Have you opted for inpatient and outpatient treatment, or just inpatient? Did you opt for a deductible? It is important to know the answers to these questions before seeking treatment.
Each policy will have a list of excluded conditions and treatments, for example cosmetic treatment, so it’s best to be aware of these at the outset. You may also have excluded conditions and treatments that are specific to you, based on the medical information you declared on the application form. You will have been told about these when you joined.

You should also pay attention to the area of cover that applies to your policy as it determines where you can have treatment. Your policy may restrict you to having treatment in Africa only, Africa & India, or Africa, India & Europe, or you may have opted for a policy that allows you to have treatment anywhere in the world excluding, or including, the USA. Please note that this applies to virtual services as well.

Be aware of any benefit limits.

Certain benefits may be limited. For example, some policies set a maximum monetary amount that can be spent on outpatient treatment per person, per annum. Other benefits, such as physiotherapy, may be limited by the number of sessions. It makes sense to be aware of these limits, especially if you have made a number of claims in a policy (not calendar) year so you know how close you are to exhausting the benefit.

And other benefits may require a contribution from yourself, for example routine dental treatment. It is always best to know in advance of having any treatment, to avoid any surprises after the event.

Benefits may also be limited by what insurers refer to as ‘reasonable & customary’ which essentially means expenses are line with what is typically charged in the locality. This is another reason for informing insurers of planned treatment well in advance.

The paperwork is vitally important.

Whichever insurer your policy is with, they will want to see supporting documents such as doctors’ notes (describing the symptoms, diagnosis, recommended treatment), medical reports, prescriptions, hospital bills, invoices, and receipts, so always keep these safe. To avoid unnecessary delay, you should supply all the information the insurer asks for, making sure that any photos or scanned copies are clear and that the names on documents tally exactly with the names on the policy.

Sign up for online portals and apps now

We recommend you check out if your insurer offers an online portal or app, and if so, sign up now. For straightforward claim reimbursements, claiming though your insurer’s online portal or app is usually the easiest and quickest way.

If you use this route, make sure any document uploads are legible and please make sure you complete the bank details in full to avoid any delay in reimbursement because of incomplete bank details.

As well as being able to submit claims, you will also be able to see details of your policy, and search for network doctors, clinics, and hospitals, amongst other things.

Remember we are here to support you with your claims

The team is available to help make the claiming experience as smooth as possible. If you let us know about any treatment, we will share our knowledge and expertise to inform and advise, as well as deal with the insurer on your behalf before, during and after treatment.

Please get in touch with your Client Relationship Manager or contact us on talk2us@jwseagon.com or Tel: + 254 (0) 709 455 000 for more information.