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What Is A Health Insurance Claim?

Simply put, a health insurance claim is a claim filed to avail of the benefits of a health insurance policy. You can claim health insurance by submitting a request with your health insurance provider. After the assessment of your health insurance claim request as well as the supporting documents, the insurer shall settle your claim.

What Are The Different Types of Health Insurance Claims?

There are two main types of health insurance claims, namely cashless claims and reimbursement claims. Both types of claims have been discussed below.

  • Cashless Claim For Health Insurance

A cashless health insurance claim is one wherein you need not pay the bills of your medical treatment and/or hospitalisation. After receiving such a claim request and verifying it, your health insurance provider shall make the payment of the bills to the relevant network hospital.

  • Reimbursement Claim For Health Insurance

If you receive medical treatment at a hospital that is not in the list of the network hospitals of your health insurance provider, then you must pay the bills yourself and file a reimbursement claim later. The insurer shall check the claim and the necessary supporting documents and settle the claim by reimbursing the cost of the medical expenses.

What Is The Procedure For Filing A Cashless Claim For A Planned Hospital Admission?

You can benefit from the facility of cashless insurance if you get treated at one of the network hospitals of your health insurance provider. The list of network hospitals is available on the website of the insurer and you can check the network hospital nearest to you. There are two scenarios within which you can file a cashless claim, namely a planned admission to a network hospital and an emergency admission.

 

If you are wondering how to claim health insurance via cashless claims if you have a scheduled admission at a network hospital, then here are the steps you need to follow.

 

  1. Contact your health insurance provider before getting hospitalised and inform them of the planned hospital admission. You can do so via email or phone.

  2. After getting admitted to a network hospital as scheduled, go to the insurance desk, show your health insurance card, and request a pre-authorisation form.

  3. Ensure the submission of the duly filled pre-authorisation form from the hospital to the insurer.

  4. The insurer will check your health insurance pre-authorisation form and the other supporting documents and process your cashless claim.

  5. The bills for your hospitalisation and any other associated costs (if covered under your health insurance policy) shall be directly paid to the hospital by your health insurance provider.

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What Is The Procedure For Filing A Cashless Claim For An Emergency Hospital Admission?

If you get admitted to a network hospital following a medical emergency, for instance, an accident or a heart attack, to name a few, then your dependents can inform your health insurance provider about the hospitalisation. It is advisable that such an intimation must take place at the earliest time possible after your admission to a hospital.

 

The duly filled pre-authorisation form is required to be submitted to the insurer within the 24 hours of your admission to the hospital. After verifying your claim and the supporting documents, if any, your insurer shall settle the claim with the network hospital. The process of filing a cashless claim in health insurance is, thus, extremely simple.

 

READ MORE: Incurred Claim Ratio in Health Insurance

 

What Is The Procedure For Filing A Reimbursement Claim?

You can also claim your health insurance by opting for a health insurance reimbursement claim. This type of health insurance claim is useful if you receive medical treatment at a non-network hospital. Here is how you can file a reimbursement claim with your health insurance provider.

 

  1. Receive the required medical treatment and get admitted to a hospital (if required).

  2. Pay the bills of the medical treatment, including hospitalisation (if applicable).

  3. File a health insurance reimbursement claim with your insurer and submit the original bills of the cost of the treatment.

  4. Await the processing of the claim at the insurer's end.

  5. You will receive the reimbursement of the cost of the treatment as long as it is covered under your health insurance policy and does not supersede the sum insured under the policy.

  6. You can keep track of the latest status of your health insurance claim at the official website of your health insurance provider.

What Are The Documents Required To File A Health Insurance Claim?

Whether you are filing a cashless claim or a reimbursement claim on your health insurance policy, there are certain important documents that are required to be submitted. Here are the documents required to claim health insurance.

 

  1. Your Health Insurance Identity Card

  2. Documents detailing Doctor's Consultation

  3. Duly filled health insurance claim form

  4. Your medical bills and reports, including hospital admission and discharge slips (in case of hospitalisation)

  5. A copy of the First Information Report (FIR) filed with the police (in case of accident)

  6. A copy of your prescription and pharmacy bills

  7. Other relevant documents

What Are The Reasons For The Rejection of Health Insurance Claims?

There are several reasons why your health insurance claim may be rejected. Here are the major reasons behind health insurance claim rejection.

 

  1. Submission of a claim perceived as being fraudulent by your health insurer

  2. A claim filed for an expense that is excluded from your health insurance policy

  3. A claim filed on a lapsed health insurance plan

  4. A claim for an expense that is not covered under your health insurance policy

  5. A claim filed for a cover before the expiration of its waiting period

Important Points To Keep In Mind While Filing Health Insurance Claims

Whilst filing a health insurance claim, you must be mindful of certain important things, for instance:

 

  1. The inclusions and exclusions under your health insurance policy, particularly pertaining to hospitalisation

  2. The Room Rent Limits mentioned in your health insurance policy

  3. The minimum waiting period for different covers under your health insurance policy

  4. The co-payment clause of your health insurance policy

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

To Sum It Up

It is easy to claim health insurance, particularly with the flexibility to file health insurance claims online and opt for cashless claims. You must be well acquainted with the health insurance claim procedure and follow all the steps required to file a claim. 

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Frequently Asked Questions About The Health Insurance Claims Process

  • ✔️What is a health insurance claim?

    A health insurance claim is a request that you have to submit to claim your health insurance benefits. 

  • ✔️What are the different types of medical claims?

    There are two main types of health insurance claims, namely:

    • Cashless claims

    • Reimbursement claims 

  • ✔️What is a health card?

    A health card is an identity card issued by your health insurance provider. This card is an important document to claim your health insurance, particularly during hospitalisation. 

  • ✔️Can I file a health insurance claim online?

    Yes, you can file your health insurance claim on the official website of your health insurance provider or the official website of Finserv MARKETS. 

  • ✔️What will happen if I file a health insurance claim on a policy that has expired?

    If you file a claim on a health insurance policy that is no longer valid, then your insurer shall reject the claim. It is, therefore, advisable to renew your health insurance plan on a timely basis. 

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