cover_img

Uncomplicating Health Insurance

with our certified POSP
advisors to guide you

Health Insurance Claim Process

A health insurance claim is a request submitted by the insured to the insurance company to obtain the coverage benefits mentioned in the policy. The policyholder can opt for either direct claim settlement (also known as cashless treatment) or reimbursement of the medical expenses.

Types of Health Insurance Claim

Provision of healthcare services in an emergency is the actual reason for buying a health insurance plan. To ensure efficient and quick settlement of medical costs, you must initiate the claim on time. There are two ways that you can claim a health insurance plan:

Cashless Treatment

In this type of claim, the insurance company settles the hospitalization bills directly with the hospital. However, you can only opt for the cashless claim facility if you get treated at one of the network hospitals of the insurance company.

Here are the steps involved in the cashless health insurance claim process:

  • If you are seeking planned hospitalization, inform the hospital 3 to 4 days before the hospitalization.
  • A pre-authorization form must be filled and submitted to the insurance company.
  • If the hospitalization is unplanned, the insurance company needs to be notified, and the pre-authorization form must be submitted within 24 hours of hospitalization.
  • The insurance company will review all the documents submitted along with the pre-authorization form and allows the policyholder to obtain a cashless treatment facility.
  • After the treatment, all the medical bills, medical reports, and other documents must be submitted to the insurance company.
  • Some insurers also assign a field doctor to make the process easier for the policyholder.
  • The insurance company directly settles the medical costs with the hospital.

Note: Cashless treatment facility can be availed of at network hospitals only.

Reimbursement Claims

In this type of health insurance claim process, the policyholder pays the costs upfront and then submits a request for reimbursement of the bills. You can opt for reimbursement facility in a network as well as non-network hospitals.

Here are the steps involved in the reimbursement claim process:

  • If the insurer is hospitalized at a non-network hospital, a reimbursement claim needs to be filed.
  • All the original medical bills and reports must be collected by the insured.
  • The insured must pay the bills from their own pockets initially.
  • At the time of discharge, the policyholder must collect a Discharge Summary from the hospital.
  • The Discharge Summary/Discharge certificate is submitted to the insurance company and other documents like a duly filled claim form, medical reports, bills, and other documents.
  • The insurance company verifies the claims. If the claim is accepted, the insurance company reimburses the costs paid by you.

Authorization Process of Health Insurance

As soon as the insurer receives an intimation from the attendant of the insured and is contacted by the network hospital for the same, the insurer verifies the validity of the policy and the policy's coverage. Then, a field doctor is assigned who helps to fill the pre-authorization form and cross-check if the patient needs the treatment claimed. After all the documents, including medical tests, are verified by the medical team of the insurance company, the company approves the cashless treatment request according to the terms and conditions mentioned in the policy. In case of reimbursement claims, the medical bills and other documents are submitted to the insurance company. After verification, the insurance company reimburses the costs according to the terms and conditions of the policy.

What Are the Documents Required to File a Health Insurance Claim?

You can file a health insurance claim with the insurance company. If you visit a network hospital, the insurance company will settle the claim with the hospital. In case you do not visit a network hospital, the bills will be reimbursed to you later:

  • Claim form
  • Medical Certificate
  • Hospitalization Bills
  • Doctor's prescriptions (Throughout the medication and hospitalization)
  • Copy of FIR (in accident case)

For Reimbursement Claims, the Documents Required Include:

When you opt for a health insurance claim reimbursement, you need to keep detailed records of all bills. Some documents of the hospitalization that you would be required to furnish include:

01

Discharge card

02

Pre-signed and filled up hospital bills

03

Bills from the pharmacy and in-hospital disposables

04

Health Insurance Claim form filled up correctly with the insured signature

05

Patient reports and charts

06

ID card of TPA (Third-Party Administrator)

07

Insurance policy document copy

08

Cancelled cheque and ECS authorization to allow the insurer to deposit in your bank account

08

KYC documents for ID purpose

How To File a Health Insurance Claim?

Health insurance plans come with benefits like cashless hospitalization and reimbursement. Below are the steps on how you can file a health insurance claim:

In Case of Planned Hospitalization:

  • Inform the insurance company about the hospitalization 72 hours before, either online or by calling them on their number
  • Once you get approval, you can file a claim later
  • In case of hospitalization, you must share the details of the group insurance policy with the hospital
  • The insurance company will ask the policyholder for the relevant documents along with the claim form
  • If the claims are verified, the insurance company settles the bill on behalf of the policyholder.

In Case of Emergency Hospitalization:

  • Inform the insurance company about the hospitalization within 48 hours of getting hospitalized.
  • Show your health card at the hospital to initiate the health insurance claim process.
  • The insurance company will ask the policyholder for the relevant documents along with the claim form.
  • If the claims are verified, the insurance company settles the bill on behalf of the policyholder.

If you are not hospitalized in a network hospital, you need to find a reimbursement claim later.

Points to Remember

There are certain points that you need to consider when you file a health insurance claim. These points help in the quick and easy settlement of claims. The points are:

01

Documents

The policyholder should be aware of the documents required to file a claim. Along with the pre-authorization form, medical bills, and medical test reports, you need to produce ID proof, a copy of the policy document, and any other documents as required by the insurance company.

02

Sum Insured

The health insurance claim can only be filed up to the sum insured limit as stated in the policy. If the bill exceeds the sum insured, the excess must be paid by the policyholder. So, it is important to know the sum insured mentioned in the policy before you file a claim.

03

Exclusions

There are some medical treatments and surgeries that are not covered under the health insurance policy. These are known as exclusions, and these are mentioned in your policy. If you make a claim for an excluded medical treatment, the claim would be rejected. It is important to check the exclusions in a policy not to file a claim for them.

04

Timeline

In cashless treatment, there is a timeline within which you must submit the pre-authorization form. If it is a planned treatment, you must submit the pre-authorization form 3-4 days before hospitalization. If it is an unplanned hospitalization, the health insurance claim form needs to be submitted within 24 hours of hospitalization. It is necessary to adhere to the timelines so that you do not face any issues in availing of a cashless treatment facility.

05

List of Network Hospitals

A cashless treatment facility can only be availed of at the network hospitals of the insurance company. If you wish to make use of the service, you can check the list of network hospitals of the insurer. The list is mentioned on the insurer's website, and you can also obtain it from other online sources.

06

Validity of the Policy

The coverage benefits under the health insurance policy can only be availed of if the policy is active and not lapsed. If the policy has lapsed, the claim will be rejected. So, it is important to pay the premiums on time so that the policy remains active, and you can use the benefits if there is a medical emergency.

Bottom Line

Thus, you should have all the information about the health insurance claim process if you want a speedy and efficient settlement of claims. It is important to contact your insurer if you have any doubts regarding the claim process or the network hospitals. Before you buy a policy, you should also consider the claim settlement ratio of health insurance companies.