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Knowing the process of filing a health insurance claim is crucial to getting timely financial assistance. Be it an emergency or a planned medical procedure, all you need to do is submit the necessary documents to your insurer. 

 

Opt for a cashless or reimbursement claim and follow the process as well as timelines set by the insurance provider. On Bajaj Markets, you can claim an amount of up to ₹2 Crores at a monthly premium starting at just ₹160.

Important Update (Dated May 30, 2024) – Good news for Health Insurance policyholders! According to the Master Circular on Health Insurance Business 29052024 rolled out on May 29, 2024 by IRDAI, insurers are to decide on the request for cashless claims within 1 hour of receiving the request. Also, the final claim is to be granted within 3 hours after the policyholder’s discharge from the hospital. Insurers have been directed by IRDAI to establish necessary systems and procedures for this process by July 31, 2024.

 

The Master Circular on Health Insurance Business 29052024 circular is available here - https://irdai.gov.in/document-detail?documentId=4942918

Types of Health Insurance Claims

There are primarily two types of medical claims as listed below:

  • Cashless Claims

You do not need to pay bills related to hospitalisation as well as other medical treatment charges upfront, as per the policy terms. Your insurance provider is responsible for directly setting bills with the relevant hospital.

 

Earlier, cashless claims required the medical facility to be listed on the insurance provider’s network. This has not been the case since early 2024 when the General Insurance Council (GIC) launched the 'Cashless Everywhere' initiative. 

 

Now, you can file cashless claims at any hospital, provided you follow the guidelines listed by the GIC. However, visiting a network hospital can still offer you a quicker, seamless and more reliable claim settlement process. Check the list of partner hospitals by calling the insurer’s customer service or on its website. 

  • Reimbursement Claims

When filing a claim for reimbursement, you need to pay medical expenses from your own pocket initially. After treatment, raise a request for compensation with your insurance company. 

 

The insurer checks your claim details and the supporting documents. If approved, it settles the claim by reimbursing your healthcare expenses as per policy terms.

Health Insurance Claim Process

It is best to go over the policy document when you get it by email, so you can be informed about the process to follow. Different health insurance companies may have variations in the steps, guidelines or deadlines. Here are the common steps to file a medical claim:

1. For Cashless Claims

  • In case of planned treatment, follow the process below:
  • Select any hospital for treatment 

  • Notify the third-party administrator (TPA) at least 3 days before admission and get a membership number

  • Fill out the required form for cashless treatment at the hospital

  • Submit the duly filled form and your medical documents to the TPA for verification

  • After approval, the insurance company will directly settle the bills with the hospital

 

In case your request gets disapproved initially, you can file for reimbursement later. 

 

In the case of an emergency admission, follow the process mentioned here:

  • Inform the TPA and provide your membership number within 24 hours of admission, if possible 

  • Fill in the cashless application form given by the hospital and get it certified by a doctor

  • Submit the form and medical records to TPA

  • Once approved, the insurance company will settle your hospital bills directly

 

In case you are not visiting a hospital in your insurer’s network, follow these timelines to notify it as per the GIC:

  • For planned/elective treatment, notify your insurer at least 48 hours prior to admission.

  • During emergency procedures, contact your health insurance provider within 48 hours of admission.

2. For Reimbursement Claims

The formalities when you file a claim to be reimbursed for healthcare expenses hinge on submitting the right paperwork. Here is the general process to follow:

  • Contact your insurance company and provide the membership number within 2-15 days of admission, based on your insurer’s terms 

  • Clear your hospital bills in full and collect all the related paperwork

  • Download the reimbursement form from the insurance company’s website and fill it out

  • Submit the form along with medical records, such as original copies of the bills, discharge summary, prescriptions, and other documents when requesting reimbursement

  • Once the request is approved, you will receive the reimbursement amount in your bank account or via cheque 

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Documents Required to File a Health Insurance Claim

To file a claim for health insurance, provide these documents to the insurance company along with a completed application form:

  • Age Proof: Birth certificate, Driving licence, 10th or 12th marksheet, passport, Aadhaar card, Voter’s ID, or PAN card

  • Identify Proof: Passport, Aadhaar card, Driving licence, Voter’s ID, or PAN card

  • Address Proof: Passport, Aadhaar card, Driving licence, Voter’s ID, PAN card, or utility bills

  • Medical Documents: Original reports of the required medical tests, discharge card, medical certificate, prescriptions, and more

  • Passport-size Photographs

Kinds of Expenses You Can Claim Under Health Insurance

You can file a claim with your insurance provider for the following services:

  • In-patient hospitalisation expenses

  • Pre- and post-hospitalisation expenses

  • Expenses for medicines and prescriptions

  • Maternity expenses

  • Expenses for outpatient services

  • Ambulance charges

  • Preventive care expenses

  • Expenses for day care treatments

Things to Keep in Mind When Filing a Health Insurance Claim

Here are some key points to consider before initiating the insurance claim process:

  • Type of health insurance you have 

  • Total tenure of your medical insurance

  • Timeline for requesting a claim

  • Terms and conditions of the insurer with regard to claim process and formalities 

  • Process of filing a claim

  • Proper communication with the insurer

  • Inclusions and exclusions of your medical policy 

How to Claim Health Insurance from Multiple Insurers

Follow these steps to file a claim with multiple insurance companies:

  1. Initiate the medical insurance claim process with the first insurance company

  2. Obtain the claim settlement summary from the first insurance company

  3. Get the receipts and other documents of the hospital bills

  4. Approach the second insurance company to settle the remaining expenses

  5. Submit the first claim settlement summary and all the medical documents to the second company

How to Check the Status of a Health Insurance Claim

Here are the steps to review the status of your claim request online:

  1. Visit your insurance company’s website

  2. Choose the ‘Register a Claim’ option

  3. Select the ‘Track Claim Status’ option

  4. Provide your policy number, customer ID, claim number, and birth date

  5. Click on the ‘Submit’ button to check the status on the screen

 

You can also check the status offline by calling or visiting the nearest office of the health insurance provider. Remember, the process may vary slightly from one insurer to another. You can contact the customer support team of the insurer to address queries.

Reasons for Rejection of Health Insurance Claims

Here are some reasons that can lead to the rejection of your medical claim:

  • Incorrect or incomplete information

  • Undisclosed medical conditions

  • Claim request after the expiration of the policy

  • Incomplete documents or discrepancies in paperwork

  • Claim filed for expenses or services not included in the policy

How to Avoid Health Insurance Claim Rejections

You can boost the chances of approval of your insurance claims in these ways:

  • Inform the third-party administrator beforehand and fill out the cashless treatment form at the hospital carefully

  • Cross-check the terms and conditions of your policy 

  • Submit the request for claims as soon as possible 

  • Understand and follow the claim procedure accurately

  • Keep the required documents handy 

  • Check the list of network hospitals included in the plan

  • Review the treatments included and excluded in the policy

  • Disclose your medical conditions and other details properly when getting the policy

  • File for a claim before the tenure of the insurance policy ends

  • Renew your health insurance policy by paying the premium prior to the due date

Health Insurance Plans Available at Bajaj Markets

FAQs on Health Insurance Claims

What will happen if I file a medical insurance claim under a policy that has expired?

If you file a claim under a health insurance policy that is no longer valid, your insurer will reject the claim. Renew your health insurance plan on time to benefit from coverage.

How to claim health insurance?

You can claim health insurance in two ways: cashless and reimbursement mode. Under cashless claims, you do not have to pay medical bills upfront. Under reimbursement claims, you pay for health expenses yourself and later file to be reimbursed.

What are the two types of health insurance claims?

Cashless claims and reimbursement claims are two types of health insurance claims. In a cashless claim, you will not have to pay for medical expenses yourself. The insurer will directly settle the bills with the network hospital. 

 

In a reimbursement claim, you pay the medical expenses yourself and then file a claim with your insurer by providing necessary evidence. The insurance company credits the amount to your account after verification. 

What are the documents required to file a health insurance claim?

The documents that you need while filing a health insurance claim include age proof, address proof, identity proof and claim form. You also need to provide medical reports, discharge summary, cancelled cheques and payment receipts, among other documents. The specific list depends on the type of claim you are filing and the insurer’s policies.

How much time does it take for a cashless and reimbursement claim to be settled?

While the timeline depends on the insurer, a cashless claim may be settled by a health insurance company in just three hours. An insurer may settle a reimbursement medical claim in about 20 days.

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