A health insurance claim is a request made by a policyholder to the insurance company to provide medical benefits and services covered in the health insurance policy. It is the process of obtaining monetary compensation from the insurer for all incurred medical expenses. The policyholder can either get the cost of medical services reimbursed by the insurer or opt for direct claim settlement (also known as cashless claims).
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Providing financial assistance for healthcare services is the sole purpose of a health insurance plan. A health insurance claim needs to be raised to obtain this financial support at the time of need. A policyholder can raise two types of health insurance claims. They are:
In this type of claim, the insurer settles all the medical bills with the hospital directly. However, an insured needs to be hospitalized only at a network hospital to get the benefit of cashless hospitalization.
In this type of claim process, the policyholder pays for the hospitalization expenses upfront at the time of discharge and requests the insurance company for reimbursement later. Reimbursement claims can be raised at both network and non-network hospitals.
Take a look at the both health insurance cashless and reimbursement claim process below:
The step-by-step procedure to avail a cashless claim under a health insurance policy is as follows:
Step 1: Get admitted to a network hospital of your insurance company and contact the insurance helpdesk at the hospital
Step 2: Show the health card issued by your insurer for identification
Step 3: The hospital will verify your identity and give you a pre-authorization form for cashless treatment.
Step 4: Fill in the pre-authorization form and submit it at the insurance desk
Step 5: The network hospital will submit the pre-authorization form to your health insurance provider.
Step 6: The insurance company will review your pre-authorization request along with the submitted documents and approve your cashless claim according to the terms and conditions of your health insurance policy. Some insurers also assign a field doctor to make the cashless claim authorization process easier
Step 7: At the time of discharge, pay for the medical expenses that are not covered by your health policy
Step 8: Your insurance company will pay the claim amount directly to the hospital as per the terms and conditions of your policy
Follow the steps given below to raise a reimbursement claim under a health insurance policy:
Step 1: Inform your health insurance provider about your hospitalization at the earliest
Step 2: Obtain treatment at the hospital
Step 3: During discharge, pay the entire hospital bills and collect all the documents
Step 4: Submit all the required documents to your health insurance company
Step 5: The insurer will review all the submitted documents and process the claim according to the terms and conditions of your health policy.
Step 6: Once your claim has been approved, the claim amount will be paid to you.
The following documents should be submitted to file a health insurance claim:
A health insurance claim can be raised for the following kinds of hospitalizations:
A planned hospitalization is the one about which the policyholder is aware beforehand. Generally, it is required for the treatment of an illness or medical condition that has been already diagnosed. In this case, the policyholder must inform the insurance company about the planned hospitalization at least 48 hours before the actual hospital admission.
An emergency hospitalization is the one that happens suddenly and is unplanned. Generally, emergency hospitalization is needed when the insured meets with an accident and needs immediate hospitalization. In this case, the family of the insured is asked to contact the health insurance provider within 24 hours of admitting the patient to the hospital.
Here are a few things to keep in mind to avail a health insurance claim:
In case you have health insurance policies from multiple insurance companies, all you need to do is raise a cashless claim with any one insurer for all the medical expenses. Once the first insurer settles your claim, contact the 2nd insurer for paying the remaining medical expenses.
You will have to submit the claim settlement summary from the first insurer along with the attested hospital bills and payment receipts to the 2nd insurance company. The insurer will review your claim against your policy terms & conditions and accordingly, pay you the claim amount.
The best way to check the status of a health insurance claim is by contacting the claim support team or visiting the website of your insurance provider. If you have purchased your policy from Policybazaar.com, you can also contact their claim assistance team. Alternatively, you can also visit the health insurance claim page on Policybazaar.com to know the status of your claim.
Given below are some of the most common reasons for health insurance claim rejections:
Here are a few tips to avoid the rejection of your health insurance claim:
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