Types of Claim Settlement
The claim settlement procedure can be processed by either 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 to 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.
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:
- Original investigation reports
- Pharmacy bills along with the prescription
- FIR or post-mortem report if happened
- Original bills, receipts, and discharge report
- Original hospital bills and a valid photo ID proof
- Treating doctor's report, and original consultation notes
- Final hospital discharge summary
- Indoor case papers and duly-filled claim form
- Test reports along with attending doctor’s or surgeon’s report
- 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 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.
How to Make a Reimbursement for Health Insurance Claim?
Listed below is the process of reimbursement 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. Annex 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 Claim
Given below are some common reasons that result in the rejection of health insurance claims by insurance providers:
- On making a fraudulent claim by the policyholder
- If you raise a claim for an exclusion of your health plan
- Raising a claim on the basis of an expired insurance policy
- Asking for a claim for the treatment not listed under the health plan
- Getting treatment for a pre-existing illness without completing the waiting period
Health Insurance Claim FAQs
Q1. 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.
Q2. 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.
Q3. 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.
Health Insurance Claim Settlement
- Religare Health Insurance
- Max Bupa
- Star Health Insurance
- ManipalCigna Health Insurance
- HDFC ERGO General Insurance
- HDFC ERGO Health Insurance
- Royal Sundaram General Insurance
- Universal Sompo General Insurance
- Aditya Birla Health Insurance
- Edelweiss General Insurance
- New India Assurance
- Reliance General Insurance
- Tata AIG General Insurance
- Bajaj Allianz General Insurance
- Liberty General Insurance
- United India Insurance
- IFFCO Tokio General Insurance
- ICICI Lombard General Insurance
- Future Generali India Insurance
- Bharti AXA General Insurance
- SBI General Insurance
- National Insurance
- Cholamandalam MS General Insurance
- Oriental Insurance
- Raheja QBE General Insurance
- Magma HDI General Insurance
- Go Digit General Insurance
- Reliance Health Insurance
- DHFL General Insurance