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Health Insurance Claim

A health insurance claim is a request that a health insurance policyholder submits to the Insurance Company in order to obtain the services that are covered in their health insurance policy. A health insurance policyholder can either get reimbursed or can opt for direct claim settlement option (also known as cashless treatment) for the availed medical services. In this way, one can either submit the claim form or request the health insurance provider cashless services.

Types of Health Insurance Claim

Providing healthcare service when needed is the true utility of a health insurance plan. To ensure timely and easy settlement of all the medical expenses, one needs to initiate the health insurance claim process. There are two ways to claim a health insurance policy:

Cashless Claims :

In this type of health insurance claim, the insurer settles all the hospitalization bills with the hospital directly. However, an insured needs to be hospitalized only at a network hospital to get the benefit of cashless hospitalization.

Reimbursement Claims :

In this type of claim process, the policyholder pays for the hospitalization expenses upfront and requests for reimbursement by the insurance provider later. One can get reimbursement facility at both network and non-network hospitals in this case.

The Authorization Process for Health Insurance

As soon as an insurer receives the intimation from the attendant of the policyholder and is contacted by the hospital (network) about the same, the insurer verifies the validity of the policy and policy coverage of that policyholder. Then, a field doctor is assigned to facilitate the request for the pre-authorization document and to cross-check the claimed treatment. After verification, the medical team from the insurance company approves the cashless claim for the policyholder according to the terms and conditions of the policy.

Important Conditions to Avail Health Insurance Claim

  • The authorization process may be cancelled, if the details are not filled completely.
  • All the claims must be filed within 30 days from the discharge date.
  • The insured has to pay for all the non-payable items on their own.
  • To claim the entire post-hospitalization expense, one must submit all the relevant documents within 30 days from the discharge date.

Health Insurance Claim Process

Claim Settlement Process for Cashless Claims

The general procedure to avail cashless claim for a health insurance policy is:

A Health Insurance Cashless Claim can be of two types:

Planned Hospitalization

Planned hospitalization comes in picture when the policyholder is aware of the hospitalization beforehand. The steps to claim cashless treatment in this case are:

  1. Contact the toll-free helpline number of the health insurance policy provider beforehand.
  2. Fax the pre-authorization form, which must be duly filled by the hospital, to the fax number of the health insurance provider.
  3. Contact the toll-free helpline number of the health insurance policy provider beforehand.

Emergency Hospitalization

Generally, an emergency hospitalization is needed when the insured meets with an accident or is suffering from an illness that needs immediate hospitalization.

  1. In such a situation, the family of the insured is asked to contact the health insurance provider on their toll-free number after admitting the patient to the hospital.
  2. Now, the pre-authorized form (fully-filled) has to be faxed on the numbers of the health insurance provider within 24 hours of hospitalization.

Note: The toll-free numbers and the numbers on which the fax must be sent are generally mentioned on the policy documents and/or on the insurance ID card of the policy holder.

Claim Settlement Process for Health Insurance Reimbursement Claims

The general procedure to avail reimbursement claims for a health insurance policy is:

  • Contact the insurance help desk at the hospital.
  • Show the ID card of the insured, provided by the health insurance provider, for the purpose of identification.
  • The hospital will verify the identity of the insured and will submit the pre-authorization form to the health insurance provider of the insured.
  • The insurance provider will review all the submitted documents and process the claim according to the terms and conditions of the health insurance policy.
  • Some of the health insurance providers also assign a field doctor to make the hospitalization process easier for the insured.
  • After the completion of all formalities, the claim is settled as per the terms and conditions of the policy.

Documents Required for Health Insurance Claim Submission

Health Card (Health Insurance ID Card)

All the consultation papers provided by the doctor

Completely filled claim form

All the investigation and diagnosis reports, such as CT scan, X-ray, blood reports, etc.

In the case of an accident, provide the Medico Legal Certificate (MLC) or/and FIR.

Invoices of the pharmacy with respective prescriptions.

Discharge summary

All other relevant documents

Note: All the documents, other than the Health Card of the health insurance provider, must be submitted in original.