Health Insurance Claim Process

The claim settlement process is one of the most important aspects of a health insurance policy. A policyholder can settle his/her claim through the insurance company in two ways i.e. through a cashless claim process and reimbursement claim process. Here, we will discuss in detail both the methods of claims processing.

Types of Health Insurance Claim

There are two main types of health insurance claim which an individual can choose from-

Cashless Claim Process

Under this claim process, the insured needs to take treatment only at a network hospital. The treatment will start only after the insured individual provides his/her health insurance details to the hospital. After the patient is discharged from the hospital, all the medical bills are sent to your insurance provider by the hospital. After receiving the medical bills, the insurance company will then evaluate the expenses incurred and settle the payment.

However, the claim process for treatment at a cashless network hospital varies according to the type of treatment i.e. Planned or Unplanned.

Claim Process for Planned Treatment at the Cashless Network

Under this claim process, the insured needs to inform the insurance provider of the hospitalization/treatment requirement beforehand to avail of cashless treatment. The company should be informed at least 4 days before the date of hospitalization. A cashless claim request form should be submitted at the relevant address of the insurance provider via a post, e-mail, or fax. To get more information, you can also contact the customer care of your health insurance provider. Once these steps are completed, the insurance provider will notify the insured as well as the concerned hospital regarding the policy cover and eligibility. On the day of admission to the hospital, the policyholder needs to display his/her health insurance card along with the confirmation letter. After that, the medical bills will be paid directly to the hospital by your insurance provider.

Claim Process for Emergency Treatment at the Cashless Network

Under this claim process, the policyholder needs to contact the customer care of an insurance provider to get the information about the nearest network hospital. To avail of the cashless treatment, policyholders need to display their health insurance cards. After that, the hospital will fill and send the cashless claim request form at the relevant address of the insurance provider either via post, e-mail, fax, or through customer care. Then, an authorization letter will be issued by your insurance provider to the hospital, indicating the policy coverage. The medical bills will be directly paid by your insurance provider to the hospital after doing the investigation. If in the case, your claim has been rejected, a letter will be sent to you, stating the reason for rejection.

Reimbursement Claim Process

In the reimbursement claim process, the insured individual who has taken the treatment at a hospital of his/her choice will have to pay for the entire treatment until discharge. Once the insurer has paid for the treatment and hospitalization costs incurred, he/she will have to make a reimbursement claim to their insurer. The insured will also have to provide original bills of the hospital to their insurance provider for claiming the reimbursement. The insurance company will then evaluate your claim before making a payment. In case the treatment is not covered under the policy, the claim will be rejected for which the company will send you a letter stating the reason for rejection.

Documents Required for Claiming Reimbursement

  • While claiming for the necessary health insurance cover, policyholders would be required to submit the following documents. These include:
  • Health Card (Health Insurance ID Card)
  • Consultation papers provided by the doctor
  • Claim Form
  • In the case of an accident, provide the Medico-Legal Certificate (MLC) or/and FIR
  • Discharge summary or card (original), availed from the hospital
  • All hospital bills and receipts (original)
  • Prescription and cash memos from pharmacies/ hospital
  • Investigation Report

Bottom Line

Buying a health insurance policy is seamless. However, claiming insurance can be challenging if you are not aware of its process. So, it is important to think ahead and know about the process of claiming your medical expenses before buying any medical insurance cover.