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All About Health Insurance Claim Process

Updated On Feb 12, 2021

A health insurance provides you financial coverage against any unforeseen medical emergency. It comes into force whenever a policyholder has been hospitalised, diagnosed with a critical illness or disability due to an accident, or unfortunately dies. Under such circumstances, an insurance claim is initiated by the policyholder or the nominee of the life assured wherein the Health insurance company reimburses the promised life insurance cover and all medical expenses incurred by them.

There are two main ways by which the claim is settled by insurance companies. The following will help you to understand the processes better and inform you how to go about it as well -

Types of Health Insurance Claim

1. Cashless Claim

2. Reimbursement Claim

Let us now look at how insurance companies settle their claims in these two processes -

1. Cashless Claim

A cashless claim settlement occurs when an individual has a health insurance policy with a hospital network coverage. Under this coverage option, health insurance companies have an agreement with a specified list of hospitals and medical professionals and if a policyholder avails medical treatment from any one of those centres, the insurance company directly transfers the costs of diagnosis and treatment to these places and settles the bills for you. The steps involved in making a cashless claim are as follows -

Intimation -

Informing the insurance company about a cashless claim is necessary in case you have been diagnosed with an illness that requires medical attention via hospitalization. In such cases, a pre-authorization form has to be submitted to the insurance company and it should be done prior to 3 or 4 days of being hospitalized. In case of an accident and immediate hospitalization, the pre-authorization form must be submitted to the insurance company within 24 hours of the policyholder being admitted to a hospital.

All medical bills, reports and documents need to be submitted to the insurance company after treatment and if there are other costs involved, the same should also be informed to the insurance company.

Claim Assessment -

Once the insurance company has received your intimation, the insurance company will assess the claim based on the pre-authorization form and initiate the cashless claim settlement. After this, you can avail the of medical treatment without paying any extra money from your own pockets.

2. Reimbursement Claim

A reimbursement claim, as per its name, refers to the payments made by the insurance company once the costs of diagnosis, treatment and other associated payments have already been made by you or the policyholder. Such a claim is usually made towards companies, when medical intervention received by the policyholder is at a ‘non-networked’ hospital or if the health insurance policy does not have a cashless claim benefit option. The process by which a reimbursement claim can be availed is as follows-

Intimation -

Since reimbursement claims are initiated when a policyholder does not receive medical supervision under a network hospital coverage, its initiation process begins after they have been hospitalized or all medical expenses have already been paid. Once the treatment is over and the policyholder has been discharged from the hospital, they will have to obtain a Discharge certificate from the hospital where they had been hospitalized and submit it to the insurance company along with a duly filled in claim form, medical bills, reports, and health documents.

Claim Assessment -

After all your documents have been submitted, the insurance company will assess the claim filed by you and begin the reimbursement or settlement process after it is satisfied that all medical expenses have been paid by you.

However, there are certain other things that you need to be aware of before filing any kind of insurance claim from any health insurance company such as the supporting documents that you will need while filing the claim. Generally, documents required for a health insurance claim differ from company to company, as per the kind of claim that you are making. The documents that you will need for filing a critical illness claim will not be the same for filing a death claim but some papers are common for all health insurance policies, irrespective of the claim that you are making.

Documents Required For Filing Any Health Insurance Claim -

The following are a list of documents that you will need to file any kind of health insurance claims-

  • ID Proof of the Life Insured
  • Equipment charges in case of surgery or hospitalization
  • A copy of the policy bond
  • A canceled cheque

The claim process will appear to be much easier if you take cognizance of certain aspects before filing your claim. Some of the crucial aspects are as follows -

Sum Assured Limit -

Health insurance claims, whether it is cashless or reimbursement are payable only up to the amount of the total sum assured to you. If your claim amount exceeds the sum assured, the excess amount of money would have to be paid by you. Therefore, you must be careful about the insurance coverage of your health policy while filing a health insurance claim.

Exclusions -

You should remember that health insurance companies are not under compulsion to pay all expenses incurred by you. Sometimes there are payments that will have to be made by you and it will not be covered by your insurance policy in any case. These are known as exclusions and the insurance company has the right to reject a claim if it falls outside the ambit of the benefits and coverage that they offer. Hence, it is wise to take note of such exclusions before filing a health insurance claim so that even if a claim is rejected, the policyholder is aware of the reasons behind it.

Policy Term -

When you are filing a health insurance claim, you should bear in mind that it has to be paid while the policy is still in force. This is because health insurance claims filed by you will be settled by the insurance company only if your policy is still in function. For policies that have lapsed or ceased to function, all claims made towards the company would be rejected.

Therefore, you are now aware of the different types of health insurance claims and the process that you need to follow in order to reap the benefits that come with it. Hopefully, it will help you to understand and be conversant about health insurance claim processes and allow you to get the financial assistance right when you require it, without much difficulty.

Also, Read

How To Select The Right Health Insurance Policy

Common Mistakes To Avoid When Buying a Health Insurance

Disclaimer: This article is issued in the general public interest and meant for general information purposes only. Readers are advised not to rely on the contents of the article as conclusive in nature and should research further or consult an expert in this regard.

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