Health Insurance Claim

Types of Health Insurance Claims

Providing financial assistance for healthcare services is the sole purpose of a health insurance plan. A health insurance claim needs to be raised to obtain this financial support at the time of need. A policyholder can raise two types of health insurance claims. They are:

1. Cashless Claims

   In this type of claim, the insurer settles all the medical bills with the hospital directly. However, an insured needs to be hospitalized only at a network hospital to get the benefit of cashless hospitalization.

2. Reimbursement Claims

   In this type of claim process, the policyholder pays for the hospitalization expenses upfront at the time of discharge and requests the insurance company for reimbursement later. Reimbursement claims can be raised at both network and non-network hospitals.

Health Insurance Claim Process

Take a look at the both health insurance cashless and reimbursement claim process below:

Cashless Health Insurance Claim Settlement Process:

The step-by-step procedure to avail a cashless claim under a health insurance policy is as follows:

Step 1: Get admitted to a network hospital of your insurance company and contact the insurance helpdesk at the hospital

Step 2: Show the health card issued by your insurer for identification

Step 3: The hospital will verify your identity and give you a pre-authorization form for cashless treatment.

Step 4: Fill in the pre-authorization form and submit it at the insurance desk

Step 5: The network hospital will submit the pre-authorization form to your health insurance provider.

Step 6: The insurance company will review your pre-authorization request along with the submitted documents and approve your cashless claim according to the terms and conditions of your health insurance policy. Some insurers also assign a field doctor to make the cashless claim authorization process easier

Step 7: At the time of discharge, pay for the medical expenses that are not covered by your health policy

Step 8: Your insurance company will pay the claim amount directly to the hospital as per the terms and conditions of your policy

Reimbursement Health Insurance Claim Settlement Process:

Follow the steps given below to raise a reimbursement claim under a health insurance policy:

Step 1: Inform your health insurance provider about your hospitalization at the earliest

Step 2: Obtain treatment at the hospital

Step 3: During discharge, pay the entire hospital bills and collect all the documents

Step 4: Submit all the required documents to your health insurance company

Step 5: The insurer will review all the submitted documents and process the claim according to the terms and conditions of your health policy.

Step 6: Once your claim has been approved, the claim amount will be paid to you.

Documents Required to File a Health Insurance Claim

The following documents should be submitted to file a health insurance claim:

• Health Card (Health Insurance ID Card)
• All the consultation papers provided by the doctor
• Completely filled-in claim form
• All the investigation and diagnosis reports, such as CT scans, X-rays, blood reports, etc.
• Hospital bills with payment receipts
• Medico Legal Certificate (MLC) or/and FIR (in case of accidents)
• Invoices of the pharmacy with respective prescriptions and payment receipts
• Discharge summary
• Any other relevant documents requested by the insurer

Kinds of Hospitalizations that Can be Claimed Under Health Insurance

A health insurance claim can be raised for the following kinds of hospitalizations:

1. Planned Hospitalization

   A planned hospitalization is the one about which the policyholder is aware beforehand. Generally, it is required for the treatment of an illness or medical condition that has been already diagnosed. In this case, the policyholder must inform the insurance company about the planned hospitalization at least 48 hours before the actual hospital admission.

2. Emergency Hospitalization

   An emergency hospitalization is the one that happens suddenly and is unplanned. Generally, emergency hospitalization is needed when the insured meets with an accident and needs immediate hospitalization. In this case, the family of the insured is asked to contact the health insurance provider within 24 hours of admitting the patient to the hospital.

Things to Keep in Mind to Avail a Health Insurance Claim

Here are a few things to keep in mind to avail a health insurance claim:

• The cashless pre-authorization request may get denied if the form is not filled properly.
• Make sure to inform the insurance company about your hospitalization as soon as you get hospitalized.
• All reimbursement claims must be filed within 30 days from the hospital discharge date.
• Carefully go through the exclusions, sub-limits and other terms and conditions of your policy to know what exactly are you covered for.
• The insured has to pay for all the non-payable items on their own.
• To claim post-hospitalization expenses, the policyholder must submit all the relevant documents within the insurer-specified time frame.

How to Claim Health Insurance from Multiple Insurers?

In case you have health insurance policies from multiple insurance companies, all you need to do is raise a cashless claim with any one insurer for all the medical expenses. Once the first insurer settles your claim, contact the 2nd insurer for paying the remaining medical expenses.

You will have to submit the claim settlement summary from the first insurer along with the attested hospital bills and payment receipts to the 2nd insurance company. The insurer will review your claim against your policy terms & conditions and accordingly, pay you the claim amount.

How to Check the Status of a Health Insurance Claim?

The best way to check the status of a health insurance claim is by contacting the claim support team or visiting the website of your insurance provider. If you have purchased your policy from Policybazaar.com, you can also contact their claim assistance team. Alternatively, you can also visit the health insurance claim page on Policybazaar.com to know the status of your claim.

Top Reasons for Rejection of Health Insurance Claims

Given below are some of the most common reasons for health insurance claim rejections:

• Not disclosing pre-existing diseases at the time of policy purchase
• Filing a claim for treatments/illnesses not covered in the health policy
• Not raising a claim within the stipulated time frame
• Raising a claim during the waiting period
• Fraudulent claims
• Claims raised under an expired health insurance policy
• If a claim is raised for an amount more than the policy sum insured

How to Avoid Health Insurance Claim Rejections?

Here are a few tips to avoid the rejection of your health insurance claim:

• Make sure to disclose any pre-existing diseases that you may have to your insurance company
• Remember to inform your insurance company about your planned or emergency hospitalization within the stipulated time
• Make sure to go through the inclusions, waiting periods, exclusions, claim procedure and other features & benefits of your policy carefully before raising a claim
• Submit all the documents to your insurance provider in original as per requirement
• Get admitted to a network hospital to avail cashless claim facilities

Health Insurance for Claim FAQs