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Health Insurance Claim Process

As we know, we are facing a constant emergency of COVID-19 in our country and the rising cost of medical facilities is another major concern. In such a situation, buying a health insurance plan can be very beneficial for everyone as health insurance is designed to cover the expenses incurred due to the hospitalization of the policyholder. But buying health insurance is not a difficult task, but claiming health insurance can be challenging for people. It is important for everyone to understand the health insurance claim process in detail. To make it easy for you, we have explained the complete medical claim process in detail.

Types of Health Insurance Claim Process

You can file a claim against your policy in one of two ways: cashless or reimbursement claims. Below mentioned are the types of claims offered under health insurance:

Cashless Treatment

It is a type of claim in which the policyholder does not have to pay bills for medical expenses. To avail of the cashless benefit, the insured must be hospitalized at the network hospital of the insurance company. The insurance company settles the medical expense bills directly with the hospital.

Reimbursement Claims

You must first pay the hospitalization bill and then file a reimbursement claim for the hospitalization expenses. The insurer will pay you the amount as per the terms and conditions of the policy.

Health Insurance Claim Process

Health insurance can be claimed as a reimbursement claim or a cashless claim at the network hospitals of the health insurance company. Policyholders must complete the following steps to file a health insurance claim:

Cashless Claim Process

Below mentioned are the general process to avail of the cashless claim under a health insurance plan:

  • Intimate the insurance help desk in the hospital about the hospitalization.
  • Show the health card of the insured at the help desk for identification.
  • Submit the pre-authorization form to the insurer.
  • The insurance company will verify the submitted documents and process the claim per the health policy's terms and conditions.
  • Once all the formalities are done, the insurance company will settle the claim per the policy's terms and conditions.

A cashless claim process can be of two types: The planned hospitalization claim process and the Unplanned hospitalization claim process.

Planned Hospitalization

It is a type of hospitalization in which the policyholder is aware of the hospitalization beforehand. Below mentioned are the steps to file a claim under planned hospitalization:

  • Intimate the insurance company before 3 to 5 days of hospitalization.
  • The insurance company will provide a confirmation letter to the hospital.
  • Submit the health card and the confirmation letter on the day of admission of the insured.
  • The insurance company will directly settle the bill with the hospital.

 

Unplanned Hospitalization

This is also known as emergency hospitalization. This type of hospitalization happens suddenly and unexpectedly. Generally, this type of hospitalization occurs when the policyholder meets with an accident or an illness that requires immediate treatment.

  • Inform the insurance company within 24hrs of hospitalization.
  • Submit the health insurance claim form along with the other required documents.
  • The insurance company will send an authorization letter to the hospital.
  • The insurance company will directly settle the bill with the hospital.

Reimbursement Claim Process

Policyholders have to pay the medical expenses at the time of hospitalization if the insurer does not provide a cashless claim option or if the hospital is not on the list of their network hospitals. The insurance company will reimburse you for the medical bill later.

01

Inform the insurance company within the 15 days

02

Fill in and submit the health insurance claim form along with the original discharge summary and other medical bills.

03

Submit other relevant documents such as ID proof, address proof, and a canceled cheque.

04

The insurer will verify all the documents.

05

The insurer will then start the reimbursement process.

06

The insurance company will complete the claim within 21 days from the date the documents reached the health insurance company.

Documents Required for Filing Reimbursement Claim

Below is the list of documents that you need to submit while filling out a reimbursement claim:

  • Xerox Health Card
  • Duly Filled Claim Form
  • Copy of KYC documents
  • Investigation reports like X-rays, blood reports, etc
  • Original Hospital Discharge Summary
  • In case of an accident, Xerox of FIR or medico-legal certificate (MLC)
  • Doctor's Consultation Papers and Pre-Admission Investigations
  • Cash Receipts from Hospital
  • Contact details
  • NEFT details
  • Other relevant documents

Points to Remember While Filing a Health Insurance Claim

You need to consider certain points when you file a health insurance claim. These points help you in quick and easy claim settlements.

01

Documents

The policyholder should be aware of the documents required to file a claim. You must submit a pre-authorization form, medical bill, medical test report, ID proof, a copy of the policy document, and any other documents required by the insurance company.

02

Sum Insured

A health insurance claim can be filed only to the limit of the sum insured as stated in the policy. If the bill amount exceeds the sum insured, the policyholder must pay the additional amount. Hence, it is important to know the sum insured mentioned in the policy before filing a claim.

03

Exclusions

There are some medical treatments and surgeries that are not covered under a health insurance policy. These are known as exclusions and are mentioned in your policy documents. If you claim an excluded medical treatment, the claim will be denied. It is important to check the exclusions in the policy document before filing a claim.

04

Timeline

In cashless treatment, there is a time limit within which you have to inform the health insurance company and submit a pre-authorization form. If it is a planned treatment, you must submit a pre-authorization form 3-5 days before hospitalization. If it is an unplanned hospitalization, the health insurance claim form has to be submitted within 24 hours of the hospitalization. It is important to be aware of these time limits so that you do not face any problems in filing the claim.

05

List of Network Hospitals

Cashless hospitalization facilities can be availed only in the network hospitals of the health insurance company. You can check the list of network hospitals on the insurer's official website.

06

Policy Tenure

The coverage benefit under a health insurance policy can be availed only when the policy is active. If the policy lapses, the claim will be rejected. Therefore, it is important to pay premiums on time so that the policy remains active and you can avail the benefits in case of a medical emergency.

What To Do If My Health Claim is Rejected?

There can be many reasons for your health insurance claim to be rejected. You need to be aware of these situations in which your claim can be rejected.

  • The health insurance claim form is not filled in properly.
  • The claim form was not submitted to the insurance company in time.
  • You are filing a claim for an excluded treatment or disease.

What If I Do Not Get a Satisfying Reply From the Health Insurance Company?

As per the Public Grievance Redressal Rules 2017, if you do not get any response from the insurance company within a month or you do not get a satisfactory reply from them, you can approach the nearest Insurance Ombudsman under the Insurance Ombudsman Scheme.