Group health insurance is a type of health insurance that provides coverage to a group of people under a single policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy. The policyholderA person who pays a premium to an insurance company in exchange for the insurance protection provided by a policy can be an employer, an association, or any other entity that can purchase insurance for its members. In a group health insurance policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy, the bill breakup is a mandatory document required to process any claim, whether it is cashless or reimbursement.
What is a bill breakup?
A bill breakup is a detailed breakdown of all expenses related to the treatment and hospital charges incurred by the insured person during their hospitalisation. The bill breakup typically includes the following details:
- Room rent charges
- Consultation fee
- Operation theatre charges
- Medicines and consumables
- Investigations
- Packages
- Other charges
The final hospital bill is the total amount of expenses incurred by the insured person during their hospitalisation by the treating doctor. The bill should be on the hospital’s authorised letterhead with the patient’s details, including the name, age, bill number, date of admission, and date of discharge.
Why is the bill breakup important in claims processing?
The bill breakup is a document that the insured person needs to present to the third-party administrator (TPA) or insurer at the time of filing a claim. The bill breakup serves as a list of expenses incurred by the insured person during their hospitalisation. The bill breakup is a mandatory document for each policyholderA person who pays a premium to an insurance company in exchange for the insurance protection provided by a policy as per the government regulations.
Under a cashless claim, an agreement is signed between the hospital and the insurance company / TPA for all the service charges. This means when a bill is generated by the hospital, the TPA/insurer can cross-check the amount the hospital has charged. The insurance company pays expenses according to the agreement signed by them.
Under reimbursement claims, the insured person pays the final bill generated by the hospital at the time of discharge. The TPA/insurer will ask for the final bill with the breakup to check if the charges written are justified as per the policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy terms and conditions.
For example, if a person has a policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy in which room rent cappings are applicable, which is 1% of the sum insured.
The sum insured is ₹300,000
The total room rent charged was ₹20,000 for 4 days i.e ₹5000 per day. According to the policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy, the TPA/insurer is responsible for paying ₹3,000 per day only.
It means the insured person chose a room that was ₹2,000 extra per day to what was mentioned in the policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy.
This information is all written in the bill breakup with the date and expense.
What happens if the bill breakup is not provided?
The bill breakup is a mandatory document required for claims processing. If the bill breakup is not provided in the claims document, the insurance company can raise a query to the patient or hospital to provide the final bill breakup. As a result, the claim can get delayed or may get rejected, or maximum deduction can happen in the claim.
In conclusion, the bill breakup is a crucial document required for claims processing in group health insurance policies. The bill breakup serves as a list of expenses incurred by the insured person during their hospitalisation and helps the TPA/insurer verify if the charges are justified as per the policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy terms and conditions. The bill breakup also helps the insured person calculate the payable amount as per the group health insurance policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy. Therefore, it is essential to ensure that the bill breakup is provided with all the necessary details to avoid any delay or rejection of the claim.
