What Is A Health Insurance Claim?

What is a Health Insurance 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, let’s take a look at how to claim medical insurance in detail.

How Does the Health Insurance Claim Process Work

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.

Types of Health Insurance Claims

There are two types of health insurance claims, namely cashless claims and reimbursement claims:

• Cashless Claims

A cashless health insurance claim is the 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 directly make the payment of the bills to the relevant network hospital.

• Reimbursement Claims

A reimbursement health insurance claim is where you need to pay the bills from your own pocket and later raise a request for compensation with your insurer. If you opt for medical treatment at a non-network hospital that isn’t associated with your insurance provider, then you must file a reimbursement claim. The insurer shall check the claim details and the supporting documents and settle the claim by reimbursing the medical expenses.

Authorisation Process for Health Insurance

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.

Important Conditions for Health 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. 

Cashless Health Insurance Claim Process

You can benefit from the facility of cashless insurance if you get treated at one of the network hospitals associated with your health insurance provider. The list of network hospitals is easily available on the insurer’s website where you can check the cashless hospital nearest to you. However, there are two scenarios during which you may raise a cashless claim, namely planned or emergency hospitalisation: 

 a. Claim Process for Planned Hospitalisation

• Step 1: Inform your insurance provider regarding the planned treatment in advance, ideally 4-5 days before hospitalisation.
• Step 2: Locate the nearest cashless hospital where you want to seek treatment.
• Step 3: During hospitalisation, provide your cashless card, policy number and other relevant documents.
• Step 4: Collect the pre-authorisation form from the hospital insurance desk or download it from your insurer’s website. Duly fill it out and submit it to the insurer. Based on the insurance company, you might have to submit the pre-authorisation form in advance as well.
• Step 5: The insurance provider shall verify the details and notify the hospital.
• Step 6: The hospital shall send the healthcare bills and receipts to the insurer and the expenses will be directly settled as per the terms of the plan.

b. Claim Process for Emergency Hospitalisation

• Step 1: Notify the insurer regarding the claim as soon as possible. Most insurance companies have a set time duration within which you must contact the insurer.
• Step 2: Provide your cashless card, policy number and other documents to get hospitalised.
• Step 3: Collect the pre-authorisation form from the hospital insurance desk or download it from your insurer’s website. Duly fill it out and submit it to the insurer within the set time limit.
• Step 4: The insurance provider shall verify the claim details and approve them.
• Step 5: The hospital shall send the medical care bills to the insurance company and the expenses will be directly settled based on the terms and conditions of your policy.

Reimbursement Health Insurance Claim Process

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.

Documents Required to File Health Insurance Claims

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

How to Check the Status of 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.

How to Claim Health Insurance Under Multiple Insurers

It is possible to have an individual health plan 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. 

What is Claim Settlement Ratio in Health Insurance

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.

Common Reasons for Health Insurance Claim Rejection

There are times when your health insurance claim might get rejected by the insurer but what could be the cause? Here are some common reasons to keep in mind that lead to claim rejection:

• Non-Disclosure of Medical History

One of the key reasons for claim rejections is the failure to disclose your medical history while purchasing the insurance plan. Hiding any pre-existing conditions that you might have is not recommended as insurance plans do not cover such ailments without a waiting period.

• Providing Incorrect Information

Providing wrong details while buying health insurance such as your age, occupation, family medical history, income details, etc. can be another reason for claim rejection. Moreover, insurance companies might also terminate your policy for giving wrong information.

• Claim Falls Under Exclusions

Every health policy has a set of exclusions related to treatments or disorders that are not covered by the insurer. If your medical insurance claim falls under the exclusions mentioned under your plan, the medical care expenses will not be reimbursed by the company.

• Lapsed Insurance Policy

If your health policy has expired or lapsed, the insurance provider will not cover any healthcare expenses incurred. Even if the claim is filed during the grace period, no expenses will be reimbursed.

• Raising a Claim During the Waiting Period

For specific diseases, add-on covers or pre-existing conditions, a waiting period is applicable under the health plan. If any claim is filed during this period, the insurer will not cover it as the waiting period isn’t over.

Tips to Make a Successful Health Insurance Claim

To make sure you can raise a successful health insurance claim, you must note these tips!

• 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.

Important Pointers to Remember While Filing Health Insurance Claims

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

Final Thought

We hope that you have understood health insurance claims in detail and learned how to claim medical insurance. To steer clear of claim rejections and make the most of your insurance coverage, it is advised to avoid hiding anything from your insurance provider. Although you might avail a lower premium quote by not disclosing pre-existing conditions or lifestyle habits in the beginning, it will only lead to claim rejections in the future. And your insurance coverage will fall short in securing your health requirements.

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