Once an insurance policy is purchased online, a confirmation notice accompanied by a virtual card will be e-mailed to you. The print out of the virtual card, is the proof of insurance acquired online. The email also comprises information pertaining to the policy with supporting URL's for further reference.
On a later date, one shall receive hard copies of all the necessary documents along with the original insurance card via regular mail to the address stated while purchasing the policy.
Seeking Medical Help
Medical attention to sick individuals is prioritized in the US; it is generally based on the kind of illness and the physical condition of the patient. There are basically three ways to seek help in the event of a medical problem.
Emergency & 911
Urgent Care Doctor's appointment
Emergency & 911: life-threatening situations such as a cardiac arrest, respiratory problem, or an accident that need immediate medical attention are attended to in an emergency unit.
One can call 911 in case he/she is helpless and unable to move, or just feel vulnerable. Once the call is made help arrives at your doorstep in no time. The paramedics will check your vitals and try to gather information for the doctors while transporting you to the emergency.
Emergency facilities are open 7 days a week 24 hrs a day; and service is provided to any individual irrespective of the kind of insurance plan. There is a 48-hour cushion time to inform the insurance company about the event. If the insured person is not in a position to do so, anybody on his or her behalf can call and inform the company.
As per the terms defined in the policy, all emergency medical services are paid for, even if the facility visited is not enlisted in the network.
Urgent Care: Situations when a patient needs urgent attention but at the same time it is not life threatening, for instance allergies, flu, sprains etc. Visit the nearest medical service registered under the insurance company's network or covered under the support network. Either call the number given or your card or check the provider's directory online.
Doctor's Appointment: Chronic problems, physicals, periodical checkups etc. would require prior appointment with the doctors' office. Call the number on the card or go online for the provider's directory. Check out the medical offices registered under the insurance company's network or covered under the support group.
Secure all bills, receipts and any other paper involved in reference to insurance. Inform the insurance company about the appointments and visits made; this will later on help speed up your claim process.
Payment Process
When you visit the physician/hospital, show your insurance card to the reception/billing dept. They may make a photo-copy of your insurance card, and call insurance company to verify your policy, and will then bill the insurance company directly. In this case you will just have to pay the deductible amount.
In some cases where the hospital/Physician office does not accept insurance card, they may insist you to pay the bill directly to them. In this case get detailed bill/receipts and file claim with insurance company.
Claim: A claim form can be obtained from the insurance company. File the claim within the specified period/date, generally within 90 days from the day of service obtained. Follow up the process from time to time with the insurance company.
Claim Evaluation: The time taken for evaluating a claim is subjective to each case; it may take few weeks to several months depending on several factors, however the insured need to be careful with all the transcripts (bills & receipts) to ensure there is no delay on his/her behalf.
Hypothetical Situations
Case I: ( Plan Type: Comprehensive Coverage Plan)
Mr. X buys a comprehensive coverage policy of maximum coverage $50,000, with $50 deductible and 80-20% co-insurance.
One day Mr. X falls sick, suffering from flu; the condition is not serious and he needs to take an appointment at the doctor's office. Mr. X goes through the list of Physician/facility covered under the insurance network and find a physician and take an appointment.
After taking an appointment, Mr. X calls the insurance company help line to inform them about the appointment. Mr. X visits the doctor and presents the insurance card, and does the needful paperwork. The doctor prescribes some medicines after a check up. Mr. X goes to nearest pharmacy, buys the medicine and makes the full payment to the pharmacy for the medicines.
Mr. X then obtains a claim application form and fills it and submits it to the insurance company claim dept. The insurance company evaluates the claim; gathers all necessary information and begins to process the claim as per the policy norms and coverage.
Mr. X will still be responsible for any deductible/Co-insurance as stated in the policy.
Assume the total charges are 450$ (Physician charges 300$ and Pharmacy charges 150$). Mr X will be liable to pay $50(deductible) and 20% of the rest 400$, rest of it will be the paid by policy/insurance company.
Note: Most of the comprehensive coverage plans has 80-20% co-insurance clause for the first 5000$ of expenses, means insurance company pays 80% and insured pays 20% after the deductible. Any expense beyond 5000$ however is paid 100% by the insurance company after deductible.
Case II ( Plan Type: Limited Coverage Plan)
Mr. Y purchases a limited coverage plan with a $50 deductible option. Mr. Y is at liberty to go to any facility/doctor. Later Mr. Y files the claim; the insurance company will make payments as stated in the policy plan.
No matter how much the doctor charges as consulting fee, the plan will only pay as per the fixed clause stated in the policy. So, for example if the doctor charges 300$ for a visit, but the policy determines only $100 per visit, so after the deductible the insurance company will only pay the rest i.e. $50.
Tips:
Keep a copy of the insurance card in your wallet.
Must read the policy details to understand the available benefits and any limits.
Always keep handy the phone numbers and driving directions to the emergency facility in your area.
Benefits are paid as follows:
FAQ's
For a non emergency Is it necessary to go to a Provider? Can I visit any Physician of my choice?
You may, the advantage of taking service from a physician who is in insurance company's network is that they recognize and accepts the insurance plan without any hassle, their charges are reasonable and it is easy to settle their charges.
Note: This information provided is very generic in nature; one must review the policy and its details for exact coverage.
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