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How to Claim Individual Health Insurance?

In today's time, it is essential to have a health insurance policy for each individual regardless of their lifestyle and health condition. There are certain terms and procedures involved with having and claiming an insurance policy.

How to Claim Individual Health Insurance?

What is an Individual Health Insurance Policy?

An individual health insurance policy is a health cover that provides financial coverage for the medical treatment of an individual only. An individual health insurance policy provides coverage for hospitalisation expenses, pre and post hospitalisation expenses, organ donor expenses, room rent, domiciliary treatment, etc

An individual health insurance policy helps you mitigate any financial risk which may occur due to any of the following

  • An accident
  • Sudden illness or disease
  • Surgery

An individual health insurance claim can be settled in 2 ways - cashless claim or reimbursement claim. The nature of the settlement of claim depends on the type of hospital chosen by you for the medical treatment.

Individual Health Insurance - Cashless Claim Process

If you are getting treatment in a network hospital of the insurance company you can opt for a cashless claim process. Mentioned below are steps involved in the cashless claim process.

Step 1: Inform the insurer
After getting admitted in the hospital the policyholder is required to inform the insurer either directly or through TPA within 24 hours of hospitalisation. If you are opting for a cashless claim in a network hospital of the company, you can contact the mediclaim department of the hospital.

Step 2: Show the Health Card
The mediclaim department will then ask you to show your health card and provide details related to policy and insurer.

Step 3: Examination of Identity
They will then need your identity proof for the examination of identity and verification purposes.

Step 4: Approval of Documents
The Hospital's mediclaim department will provide your documents to the insurance company and they will then verify your documents for further proceedings.

Step 5: Claim Settlement
The claim will get settled by the insurance company and they will settle all the bills from their side, you wouldn't need to pay anything from your pocket.

Individual Health Insurance - Reimbursement Claim Process

In case you are getting treatment in a non-network hospital of the insurance company you would need to pay the bills from your pocket and then the insurance company will provide reimbursement amount to you as per the expenses incurred to the extent of sum insured. Mentioned below are the steps which one need to follow to get a reimbursement claim.

Step 1: Inform the insurer
After getting admitted in the hospital the policyholder is required to inform the insurer either directly or through TPA within 24 hours of hospitalisation.

Step 2: Keep Documents Ready
You would need to keep your documents ready for filing of the claim process. The documents will include a claim form which is provided to you by the company in which you provide the amount and expenses you are filing claim for.

Step 3: Submit Documents
You would then require to submit the documents asked by the insurer duly signed and stamped.

Step 4: Approval of Documents
The insurance Company will then verify and approve the documents as per terms and standards to check the authenticity of claim and evaluate the reimbursement amount.

Step 5 : Claim Settlement
The claim will then get settled by the insurance company within one month of filing the claim and you will get the amount in your provided bank account.

Documents Required For Individual Health Insurance Claim Settlement

In order to file a health insurance claim one should be ready with the required documents for the time of emergency. Mentioned below are the documents required to file an individual health insurance claim.

  • Duly filed claim form
  • Medical Certificate
  • Medical reports
  • Doctor’s prescription
  • ID proof
  • Pharmacy Invoice
  • FIR Copy(as per the case may be)
  • Mediclaim Card

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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