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Health Insurance Claim Process: A Complete Guide

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Healthcare costs are rising by the day, and a medical procedure can cause financial distress if you are not prepared for it. Hence, covering yourself and your loved ones under medical insurance for those uncertain times is wise. And when you buy this insurance product, make sure you go through the policy documents and familiarise yourself with the health insurance claims process to avoid hassles during medical emergencies.

Insurance companies allow policyholders to make two types of claims against their health plan - cashless and reimbursement. Let's understand each of these health insurance claims processes in detail.

Types of health insurance claims

There are two modes of claims in health insurance - cashless and reimbursement.

1. CASHLESS CLAIM:

This type of health insurance claims process works when you opt for a medical procedure in a network hospital (i.e., a hospital with which your insurer has a tie-up for cashless hospitalisations) of your insurance provider. In this case, the insurer will settle your bills directly with the hospital. Hence, the cashless claim settlement process requires minimum documents and is quite hassle-free.

2. REIMBURSEMENT CLAIM:

If you choose a non-network hospital for your medical procedure, you must settle the hospital bills from your pocket and then file a reimbursement claim with the insurance company. For this, you must submit original bills and receipts from the hospital to the insurance company. The entire claim settlement process can take around 3-4 weeks.

Eligibility and coverage

If you have individual health insurance or any other medical insurance policy, you are eligible to file claims only if you fulfil the following criteria —

1. Active health insurance:

To file a health insurance claim, you must have an active health insurance policy. Your insurer will reject your claim if your policy has lapsed.

2.

Intimation:

Before you opt for a medical procedure in a network or non-network hospital, you must inform the insurance company at least 48 hours in advance or as stated in policy terms and conditions. For medical emergencies, inform the insurer soon after hospitalisation or within 24 hours. Failure to do so can lead to the rejection of your health insurance claim.

3. Pre-authorisation:

If a healthcare provider prescribes a medical procedure or treatment, you may require pre-authorisation or pre-certification from your insurance provider. This simply means that you need approval from the insurer to ensure it meets the criteria for coverage. Therefore, it is wise to check the same with your insurance provider to avoid associated hassles at the time of claim settlement.

4. Cashless claims:

You are eligible to file a cashless claim only if you choose a network hospital for your medical procedure. If you opt for a non-network hospital, you must settle the bills from your pocket and file a reimbursement claim with the insurer.

5. Policy inclusions:

You can file health insurance claims only for medical procedures your health insurance policy covers. Your insurance provider will reject claims made outside the policy coverage.

6. Timely claim filing:

Health insurance claims should be filed within the timeframe specified in your insurance policy. If you fail to do so, the insurer may deny your claim.

7. Supporting documents:

When you file a reimbursement claim, you must submit a duly filled claim form, discharge summary, medical bills, and other supporting documents to the insurance provider. The insurer will verify the same before settling your claim.

Documents required for health insurance claim process

When you are filing a health insurance claim, you must submit the following documents to the insurance provider for a smooth claim process.

• Documents for cashless claims

Cashless claims require minimum documentation and are easy to file. The following are the documents you must submit for cashless claims:

◦ Pre-authorisation claim form, duly filled and signed

◦ Your valid ID proof

◦ Health insurance e-card

When you opt for cashless treatment, the insurer will settle your bills directly with the healthcare establishment. Therefore, you will not have to collect your bills from the hospital and submit them to the insurance provider.

• Documents for reimbursement claims

If you choose a non-network hospital for your medical procedure, you must submit the following documents to the insurance provider for reimbursement claim settlement:

▪ Your health e-card

▪ Your photo ID proof

▪ Proof of address

▪ Original discharge summary

▪ Doctor's prescription recommending hospitalisation

▪ Doctor's consultation slips and prescriptions for diagnostic tests

▪ Certificate from the attending doctor

▪ Prescription for medicines and original pharmacy bills

▪ Diagnosis reports of X-rays, blood tests, etc.

▪ Other original receipts from the hospital

▪ Breakup of the hospital bill

▪ Ambulance receipt, if applicable

▪ FIR, in case of an accident

Initiating a health insurance claim

If you get hospitalised for a medical procedure, the following are the steps to initiate a health insurance claim —

1. Inform the insurance provider:

Notify your insurance provider or TPA about your medical procedure at least 48 hours in advance. If it is a medical emergency, you must inform them within 24 hours of hospitalisation or as mentioned in your policy terms and conditions.

2. Fill out the claim form:

Get the cashless or reimbursement claim form from the insurance provider / TPA or download it online. Fill it out correctly and submit it to the insurer or TPA.

3. Submit supporting documents:

Attach necessary documents, such as the doctor’s consultation slips and prescriptions, certificates from the treating doctor, discharge summary, ambulance receipts, etc.

Remember to take photocopies of all your medical documents before submitting them to the insurance provider. You must submit the original documents to the insurer and keep the photocopies with you for your records.

Claim verification and processing

After receiving your claim request, the insurer will verify the same before processing it. This may involve the following —

1. Policy status:

Before proceeding with your claim, the insurer will check the status of your health plan. They will consider your claim only if your health plan is active. In case your policy has lapsed, they will reject your claim. If your health plan is active, they will proceed to the next step.

2. Claim review:

The insurer will review your claim minutely. They will check if the claim form and supporting documents are in place. They will also verify your personal details, policy number, treatment availed, and other details.

3. Policy coverage:

The insurer will verify if the medical treatment availed is covered under your health plan. They will also check the sum insured, deductible, co-payment, sub-limits, exclusions, claims made during the same policy term, and other details.

4. Network hospital verification:

If you have filed a cashless claim, the insurer will check if the hospital is in their network.

5. Pre-authorisation verification:

Since some treatments and services require pre-authorisation, the insurer will verify if you obtained the necessary pre-authorisation before opting for the medical procedure.

6. Other verifications:

The insurer will also check for fraud, billing errors, and duplicate claims.

Approval or denial of claim

If your claim looks genuine and meets all the required criteria, the insurer will approve it. However, if your claim falls under specific exclusions stated in your health insurance policy terms, the insurer will deny it. The insurer may also deny your claim on the grounds of fraud, non-submission of pre-authorisation request, incomplete information and documentation, and delay in submission of claims.

Receiving claim settlement

If the insurer approves your cashless claim after verification, they will initiate payment to the healthcare provider. They will settle your bills directly with the hospital.

If you file a reimbursement claim and your insurer approves the same, they will refund the claim amount to your bank account within 3-4 weeks from the date of receipt of your health insurance claim.

Post-claim process

If you file a health insurance claim and your insurer settles the same, you must keep the claim settlement certificate safe. You may need the same at the time of filing your income tax returns for the financial year.

In case of claim denial, you may appeal a review to address any errors, incomplete information, or misinterpretations. If you have any other documents to support your claim, you must submit them to the insurance provider for their review.

Tips for a smooth health insurance claim process

Whether you have individual health insurance, family floater or a senior citizens health insurance policy, the following tips can ensure a smooth claim process —

1. Understand your health insurance policy:

Before you file a claim, familiarise yourself with your health plan. Check the inclusions, exclusions, sum insured, waiting periods, deductibles, copayment and coinsurance clauses, network hospitals, and other details. Knowing these will make the claim filing process easier.

2. Opt for network hospitals:

If you have to undergo a planned procedure, choosing a network hospital for it will make the claim process smoother and quicker. Therefore, it is advisable to keep a list of network hospitals handy for medical emergencies.

3. Inform the insurance provider in advance:

In case of a planned procedure, you must inform the insurer at least 48 hours in advance or as mentioned in your policy documents. If it is a medical emergency, inform them as soon as possible or within 24 hours of hospitalisation. If you fail to notify the insurer within the stipulated period, they may reject your claim.

4. Collect all bills and documents:

If you choose a non-network hospital for a medical procedure, you must collect all bills, receipts and relevant documents, such as discharge summary, doctor’s prescriptions, and diagnostic test reports from the hospital. Keep them in one place to avoid hassles during the claim filing process.

5. File claims correctly:

Before you file a claim, go through the claim filing process in your policy documents. Follow the steps carefully to avoid discrepancies and claim rejections.

6. Submit claims promptly:

If you have to file a reimbursement claim, submit your claim within 1 week of getting discharged from the hospital or as mentioned in your policy terms and conditions. Many insurance providers do not entertain late claims. Late submission can also lead to a longer processing time.

FAQs

1. What are the things to keep in mind while filing health insurance claims?

When filing a health insurance claim, you must consider your policy’s validity, inclusions, exclusions, waiting periods, sub-limits, copayment and other clauses. You must file health insurance claims promptly and correctly. Most importantly, submit all supporting bills and documents for verification to avoid delay or claim rejection.

2. How long does it take for a reimbursement claim to be settled?

If you have filed a reimbursement claim, the insurer may settle it within 3 to 4 weeks. However, the claim settlement duration may vary from insurer to insurer.

3. Can I file a claim for daycare procedures and domiciliary hospitalisation?

If your insurance policy covers daycare procedures and domiciliary hospitalisation, you can file a claim for them. Most insurance companies in India offer coverage for these procedures.

4. Can I file more than one claim in a policy term?

There is no specific limit on the number of health insurance claims you can file within a policy term. In most cases, you can file any number of claims up to the sum insured by your health plan. Once the entire sum insured is exhausted, you cannot file more claims during the same policy year. However, some insurance companies entertain a specified number of claims during the policy period, so check the same with your insurance provider or in your policy terms and conditions.

5. When do insurance companies reject claims?

If you file a claim during the waiting period, the insurer will reject it. The insurer may also deny your claim in case of delay in claim intimation and late claim filing. Providing false or incomplete information, missing documents, policy lapses, and policy violations can also result in claim rejection.

Conclusion

To summarise, when buying health insurance, check the health insurance claims process to avoid any confusion later. Most importantly, inform the insurance company well in time about your claim, as late intimation can lead to claim rejection. Also, submit the claim form and supporting documents within 15 days of getting discharged from the hospital or as stated in your mediclaim policy documents.

Disclaimer: The above information is for illustrative purposes only. For more details, please refer to the policy wordings and prospectus before concluding the sales.

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