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Health Insurance Claim Settlement

Health insurance claim settlement is a procedure where a policyholder makes a request to his or her insurer in order to avail of the medical services listed under the health plan. With this, the policyholder can either receive a cashless treatment or can get reimbursement for availed treatment or health services.

In short, a policyholder can ask the health insurance provider to offer cashless service as well as can submit a claim settlement form to seek reimbursement.

Health insurance claims ratio which you should look into before buying health insurance.

Claim Settlement Ratio Health Insurance Companies in India

Health Insurance Companies Incurred Claims Ratio (ICR)* Claim Settlement Ratio (CSR)* 
Bajaj Allianz Health Insurance 77.61% 93.95%
Iffco Tokio Health Insurance 90.69% 92.88%
Care Health Insurance (Religare) 51.97% 89.59%
Max Bupa Health Insurance 50.19% 88.06%
HDFC Ergo Health Insurance (formerly Apollo Munich) 62.47% 84.08%
HDFC ERGO Health Insurance 52.58% 82.99%
Star Health Insurance 61.76% 79.34%
National Health Insurance 115.55% 78.52%
Bharti AXA Health Insurance 98.50% 77.78%
Care Health Insurance formerly Religare Health Insurance 106.54% 75.76%

*Data from IRDAI annual report 2017-2018 

Formula

Health Insurance Settlement Ratio = (Total Claims Settled)/ (Total Reported Claims + Outstanding Claims at Start of Year – Outstanding Claims at End of Year)

Types of Health Insurance Claim

1. Cashless Claim Settlement Method

When you get medical treatment at a network hospital of your health insurance, then you can attain a cashless claim. As per the Cashless Claim Settlement Procedure, you need not pay anything to the hospital for the treatment and medical services. The insurer directly pays to the hospital subject to the amount of the claim. You will need to pay only in case of co-payments or a sub-limit clause that you have chosen during the plan purchase.

2. Reimbursement Claim Settlement Method

If you get a treatment at a hospital outside the network of the insurer, you set foot in a Reimbursement Claim Settlement Procedure. As per this process, you have to pay for the treatment at the hospital and get it reimbursed later on from the insurance provider subject to the amount of the claim. The insurer is liable to pay the entire amount of claim after considering all the voluntary or compulsory sub-limits, deductibles, etc. opted by you at the time of purchasing the policyholder. 

Documents Required for Health Insurance Claim Settlement

Here are the following documents you need to have for the successful claim settlement of health insurance:

  1. Original investigation reports
  2. Pharmacy bills along with the prescription
  3. FIR or post-mortem report if happened
  4. Original bills, receipts, and discharge report
  5. Original hospital bills and a valid photo ID proof
  6. Treating doctor's report, and original consultation notes
  7. Final hospital discharge summary
  8. Indoor case papers and duly-filled claim form
  9. Test reports along with attending doctor’s or surgeon’s report
  10. Nature of operation performed and surgeon's bill and receipt

How to Make a Cashless Health Insurance Claim?

Listed below is the process of cashless health insurance claim settlement followed by the maximum insurers. However, the procedure may differ from insurer to insurer:

Step 1: Find the network hospital: Firstly, you should look for a network hospital to seek a cashless treatment 

Step 2: Intimate the insurer: Intimate the insurer about your hospitalization within 24 hours in the case of an emergency (subject to the policy wording) and 48 hours prior to the hospitalization in the planned admission case (subject to the policy wording). 

Step 3: Complete the documentation process: Visit the network hospital with your cashless card or the member ID or the policy number. Show the policy number or the member ID or health insurance card at the hospital’s insurance desk and duly fill-up the pre-authorization form available at the hospital.

Step 4: Claim Settlement: The hospital forwards your filled pre-authorization form to the insurer. At the insurance provider’s end, the claim settlement team examines and reviews the received details of the claim and conveys the hospital and policyholder about the approval or rejection.

Step 5: Payment of bills: If the insurer approves the bills, the medical bill is directly paid to the hospital, whereas, if rejected, the hospital bill has to be borne by the policyholder. 

Claim Settlement Process for Health Insurance Reimbursement Claims

Listed below is the process of reimbursement for health insurance claim settlement followed by most of the insurance companies. However, the procedure may differ from insurer to insurer:

Step 1: Intimate the insurer: First, intimate your insurance provider about your hospitalization within 24 hours in the case of emergency admission and 48 hours prior to the hospitalization in the planned admission case. The timeline in both the case varies from insurer to insurer. 

Step 2: Complete the documentation process: Visit the hospital (network or non-network hospital) with your ID. Get the reimbursement form from the insurer or you can download it from the insurer’s website. Fill up the claim form. Annexe all the documents mentioned above. Either submit them physically to the insurer’s office or send them via courier. 

Step 3: Payment of bills: After examining the documents the insurer’s claim settlement team sends the letter of approval to the policyholder. In the case of approval of the claim, the amount is reimbursed within 30 days. The reimbursement process may vary from insurer to insurer. 

Step 4: Claim Settlement: If the claim is rejected, the insured person is asked to revert to the insurer’s query or is provided with the reason for the rejection.

Common Reasons For The Rejection of A Health Insurance Claim 

Given below are some common reasons that result in the rejection of health insurance claims by insurance providers:

  1. On making a fraudulent claim by the policyholder
  2. If you raise a claim for an exclusion of your health plan 
  3. Raising a claim on the basis of an expired insurance policy 
  4. Asking for a claim for the treatment not listed under the health plan
  5. Getting treatment for a pre-existing illness without completing the waiting period

Health Insurance Claim Settlement FAQs

  • How many health insurance claims can a policyholder request in a year?

    Policyholders can request as many claims they require in a year. However, the total claim amount of different and successful requests can’t go over the sum insured of the policy. 

  • How much time does an insurer take to settle the health insurance claim?

    Generally, insurance providers settle the claim request in a period of 7 working days from receiving the last relevant document, but, none of them takes more than 30 days.

  • How can policyholders intimate the insurer about hospitalization?

    Policyholders can appraise their insurance provider through e-mail or call. They can contact their customer representatives for the same. However, different insurers may have different routes to connect them.

  • What is a health insurance claim settlement ratio?

    Claim Settlement Ratio or CSR in health insurance is the ratio of claims settled against the total number of claims admitted during a financial year. It is an accurate way to weigh an insurance company’s standing for claim settlement. For instance, if there were 100 claims admitted by an insurance company during a financial year, of which 93 have been settled, then the CSR will be 93% for that financial year. 

  • Why is the claim settlement ratio important while buying health insurance?

    Knowing the claim settlement ratio helps you understand how well a particular insurance company manages claims so that you do not face any hassle at the time of claim settlement. When buying health insurance plans online, it is important to consider the claim settlement ratio of the insurance company in order to analyse the insurance company. 

  • What is the time frame within which the claim must be reported to the company?

    In case of hospitalisation, the insurance company must be informed immediately. The time frame in planned or emergency hospitalisation may differ from insurer to insurer. 

  • What are the benefits of knowing the claim settlement ratio?

    Knowing Claim Settlement Ratio of an insurance company helps you measure an insurer’s reliability. It is important to know an insurance company’s claim settlement ratio in order to identify if the insurance company handles claims well or not. You must choose an insurer with a high claim settlement ratio as it ensures greater reliability.  

  • How to calculate health insurance claim settlement ratio?

    Claim Settlement Ratio or CSR of an insurance company is calculated by dividing the total number of claims received by the total number of claims settled during a financial year. 

  • What is an in-house claims processing department?

    In the in-house claim settlement process, the insurance company sets up a department with their own company to offer claim related services to the policyholders. However, both in-house claim settlement departments as well as Third Party Administration have an effective claim settlement process.

  • Why is it essential to submit all the documents as required by the company?

    In order to approve or reject your claim request, an insurance company needs to verify specified documents. You are required to provide the documents in original or copy (as required) and the decision related to claim will only be taken after document verification.  

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