Health Insurance Claims

Types of Health Insurance Claims

A health insurance plan comes in handy when you can use its benefits in times of medical emergencies. So, to make sure that your timely or sudden medical contingencies are financially covered, you (the insured) need to initiate a medical claim request.

In India, there are two ways in which you can claim on your health insurance plan -

1. Cashless Claim Settlement - When seeking treatment at a network hospital, the expenses incurred will be paid by your insurer directly to the hospital.
2. Reimbursement Claim - Reimbursement claim is raised when you (the insured) seek treatment at a non-affiliated hospital. If your claim request is approved, your insurer will compensate you for the medical expenses incurred.

Below, we have elaborated on each type of health insurance claim in detail to understand how it works.

A.Health Insurance Claim Process For Cashless Claims

Many insurance providers will give you a list of network hospitals when you seek insurance from them. So, in case of medical emergencies, if you are being treated in any of the listed network hospitals, you can avail cashless health insurance.

The standard process to avail cashless claim settlement is as follows –

1. Get in touch with the insurance desk at the network hospital.
2. Show the health card of the insured for identification purposes.
3. Once the identity of the insured is verified, the hospital will submit the pre-authorisation form to the insurer.
4. The insurer will assess the submitted documents and process the medical claim according to the insured’s policy terms and conditions.
5. After a successful assessment, the insurer will settle the medical and treatment expenses with the hospital directly.

Types Of Cashless Claims

It is important to note that health insurance cashless claim can be of two types:

1.Planned Hospitalisation

Planned hospitalisation happens when the insured is aware of his/her hospitalisation in advance. The steps to avail cashless claim facility, in this case, are as follows –

• First, contact the insurer and inform them about the hospitalisation beforehand.
• Email or fax the pre-authorisation that is duly filled by the hospital to the insurer.

The remaining health insurance claim process is the same as that of the standard cashless claim procedure.

2.Emergency Hospitalisation

Emergency hospitalisation comes into the picture when the insured meets with an accident or is suffering from a health condition that requires immediate care.

• In this case, the dependents of the insured need to contact the insurer immediately after admitting the patient in the hospital.
• The pre-authorisation form should be duly filled and sent to the insurer within 24 hours of the hospitalisation.

The remaining cashless settlement process remains the same as that of the standard medical insurance claim procedure.

B. Health Insurance Claim Process For Reimbursement Claims

Another way in which you can claim your policy is through reimbursement. The mediclaim reimbursement settlement usually comes into the picture when you are seeking treatment in a non-affiliated hospital. Here,are the steps to file for reimbursement of medical expenses:

1. You will have to pay for all the medical costs incurred by yourself while getting the treatment.
2. After your treatment is done, you can submit the original bills to your insurer and seek compensation for the incurred expenses.
3. The insurer will first assess the bills submitted, and upon verification, they will reimburse the amount based on your health insurance sum assured limit.
4. You can check the mediclaim status by visiting your insurer’s website.

Documents Required For Filing a Health Insurance Claim

Whether you avail cashless claim settlement or file for reimbursement, you need to submit the following documents with your insurer –

• Health Insurance ID Card
• Doctor’s consultation papers
• Duly filled medical claim application form
• Medical bills and hospitalisation reports
• Police FIR (in case of an accident)
• Pharmacy invoice or prescriptions (if any)
• Hospital discharge papers
• Other relevant documents

Common Reasons for Health Insurance Claim Rejection

Here are a few things why the insurer can reject your health insurance claim –

• In case the insurer thinks that you are making a fraudulent claim
• If the medical claim request is raised for something that is excluded from your health insurance plan
• If the claim is raised on an expired health insurance policy
• Seeking compensation for treatments and diseases that are not listed under your health insurance plan
• Seeking treatment for pre-existing illnesses without the completion of the waiting period

Tips to Make a Successful Health Insurance Claim

Make a note of the following things to make a successful claim on your health insurance plan –

• File a claim immediately (preferably within 24 hours of hospitalisation)
• In case of reimbursement, there is a waiting period of 30-45 days after filing the claim
• Usually, expenses related to telephone calls, laundry services, visitor’s pass fee, etc. are not covered under the health insurance plan
• In case of medical emergencies, it is best to raise medical claims online to save time.

A Final Thought

It is highly recommended that you keep the hospital in the loop regarding your health coverage right from the beginning of the treatment. This will help avoid any future conflicts, and the hospital will inform you immediately in case you run out of coverage. Also, to make sure the claim settlement process is hassle-free, provide all the requested documents and bills.

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