Health Insurance Claim Process

A health insurance claim is a request that you file with your health insurance provider to reap the benefits listed in a health insurance policy. To lodge a health insurance claim, you need to provide your insurer with supporting documents like medical bills, reports, admission slips, and pharmacy bills, among others. There are two different types of health insurance claims that you can file - a cashless claim and a reimbursement claim. 

A health insurance claim is a request that a policyholder raises to the insurance company to avail the benefits and facilities covered under a health insurance plan. You can file a health insurance claim by submitting a request with your insurance provider. After the assessment of your insurance claim request as well as the supporting documents, the insurer shall settle your claim. In this article,we’ll take a look at how to claim medical insurance in detail.

A health insurance claim is a process where the policyholder notifies the insurer about the medical expenses incurred to claim compensation. Based on the policy terms and conditions, the insurer is liable to reimburse the healthcare costs. The insured can raise a cashless or a reimbursement medical insurance claim under their health policy. For cashless claims, the insured must coordinate with the Third-Party Administrator or TPA and submit the required documents. However, for reimbursement claims, the policyholder must reach out to the health insurance company within the set duration.

The insurance provider verifies the coverage and policy details of the insured as soon as they receive claim intimation from the policyholder and the network hospital. A field doctor is then assigned who shall handle the pre-authorisation process and review the medical treatment. Upon verification, the insurance company will approve the cashless health claim based on the terms and conditions of the insurance plan.

Here are some pointers worth keeping in mind while filing a medical insurance claim:

• The process of claim authorisation might not proceed further if the claim details are incomplete or inaccurate.

• The policyholder has to cover the expenses that are not included in the policy details.

• The health insurance claims should be raised within 30 days after discharge from the hospital.

• The insured must submit all the relevant documents to claim the post-hospitalisation expense within 30 days since discharge. 

In case you want to seek healthcare treatment at a hospital of your choice, you can do so and file a reimbursement claim later. Here are the steps you need to follow for a reimbursement health insurance claim: 

• Step 1: Intimate the insurance provider regarding the claim at the earliest. In case of planned treatment or emergency hospitalisation, you must inform the insurer within the set time period.

• Step 2: Pay the medical care expenses incurred and have the original invoices handy.

• Step 3: Submit the original bills, insurance claim form and other supporting documents to the insurer.

• Step 4: The insurance provider shall verify the claim details and the invoices. In case any further information is required, the insurer might request other documents.

• Step 5: Based on the claim and the terms of your insurance plan, the claim will be accepted or rejected. 

• Step 6: The claim amount will be reimbursed soon if your health insurance claim has been accepted.

Whether you are filing a cashless or a reimbursement health insurance claim, you are required to submit the following documents:

• Health insurance Identity Card

• Documents detailing doctor's consultation

• Duly filled health insurance claim form

• Copy of insurance policy document

• Medical bills and reports, including hospital admission and discharge slips, in case of hospitalisation

• Copy of your prescription and pharmacy bills

• Investigative and diagnostic reports, such as X-rays, MRIs, etc.

• Copy of the First Information Report (FIR) filed with the police or Medico-Legal Certificate (MLC), in case of an accident

• Discharge summary

• Cancelled cheque, in case of reimbursement claim

• Other relevant documents

Follow these simple steps to check the status of your health insurance claims:

• For Cashless Claims: You can check the status of cashless health insurance claims at the insurance help desk in the hospital. The process will be initiated there and you will be informed of the deductibles to be cleared as well.

• For Reimbursement Claims: For the status of your reimbursement insurance claim, it is recommended to reach out to your insurance provider. You can contact them via their toll-free number or their email ID

It is possible to have an individual health insurance plans as well as a group insurance policy from your employer. Even if you have two health plans from private insurers, the question regarding filing a claim under multiple insurers might confuse you. In this case, you must raise an insurance claim with the first insurance company for the expenses incurred and get a summary of the claim settlement. Then, you can submit this report to the second insurer to get the remaining compensation. The process may differ from one insurance provider to another and thus, it is crucial to know the claim settlement procedure applicable to your insurers. 

Claim Settlement Ratio or CSR is an aspect that is considered when choosing a suitable health insurance provider. In simple terms, CSR tells you the probability of your insurance claim getting settled in the future. The Claim Settlement Ratio is estimated by taking the total number of claims settled by the company against the total number of claims received in a particular year. You can easily calculate this figure to compare and choose a suitable insurer. It is advised to opt for an insurance company with a high Claim Settlement Ratio.

 Here are a few things you can do to improve the chances of your claim being approved: 

• Ensure to fill the health insurance application form yourself.

• Avoid hiding any details and disclose your past and current medical history while buying insurance.

• Follow the claim intimation conditions and time durations while raising an insurance claim.

• Maintain the original bills and invoices along with diagnostic and investigative reports.

• Fill the claim settlement form accurately without any errors.

• Understand the exclusions, and terms and conditions applicable to your plan.

• Intimate the insurance provider regarding the claim at the earliest.

• Know the waiting period applicable to your insurance policy.

There are numerous terms and conditions associated with your health insurance that you must know while raising a claim. Not being aware of these aspects can lead to unnecessary out-of-pocket expenses or even rejection of a claim.

• The inclusions and exclusions under your health insurance policy, particularly about hospitalisation

• Room rent limits mentioned in your health plan

• The minimum waiting period for specific conditions or treatments

• The co-payment clause

• The sub-limits for various covers under your health insurance policy

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