Health Insurance Claim Process -

Once you have signed up to a health insurance plan and received your card, you are now in a position to use your health insurance benefits, should you need to do so. Health Insurance claims are the key factor in determining whether an insurer delivers as promised. As we explained in an earlier blog article, each insurance company will have its own hospital network. This is a list of hospitals where a relationship is in place between the hospital and insurance company, allowing direct billing to take place. Direct billing is when bills are settled directly between the hospital, and your insurance company. Sounds simple right? Go to a networked hospital, show your card, and hey presto bill paid.

Whilst in most cases the health insurance claim process is straight forwards, there are a few things we like to make our clients aware of;

Pre-Approval
If you are going to have a planned non-emergency surgery, you, or the hospital, will need to contact your insurance provider to obtain pre-approval. Pre-approval can take up to 10 days as the insurance provider is likely to check your medical records to see if the issue you have is pre-existing.

If you are rushed into hospital due to an accident then you would not be subject to pre-approval, as it is clear your admission is not due to a pre-existing issue.

Pay and Claim
In some cases, even when a direct billing relationship is in place, insurers may request you pay the bill and then submit a claim afterwards. This can occur with outpatient claims, especially with conditions which may be difficult to adjudicate if covered. A common example being skin issues. Cosmetic skin issues are excluded under most insurance plans. If the insurer can not decide quickly whether a condition is coverable, they will request you pay and then submit a claim. This allows them more time to look into the condition and the doctor’s notes.

If you are requested to do this, make sure you keep the original receipt, and doctors certificate, as you will need to submit both to your insurer. Copies are not acceptable in Thailand.

If you go to a hospital outside of your insurer’s network, then you will expected to claim on a pay and claim basis for inpatient and outpatient expenses.

Please remember that your health insurance card is not a credit card. It is a card which shows hospitals you hold a policy with that specific insurance company. It means that the insurance company will meet their obligations as outlined in the table of benefits and the contract you have made with them.