Knowledge Centre

How Claims Work for Health Insurance ?

Claim, is nothing but a notification you send to your insurance company intimating them about your loss it could be an illness, an accident or any circumstance where you have faced financial loss for the insured. When you make a health insurance claim it means you have suffered some kind of loss due to illness, an accident or a tragedy. Your insurance policy comes to rescue during contingency situation, and undoubtedly that’s the whole purpose of having an insurance plan, basically to protect you at the time of need. However, it’s not as simple as it seems like. There are several processes and theories that work around on how a claim has to be filed for a health insurance plan also why it is important to know the claim settlement ratio for health insurance companies.

Why do you file a claim with your health insurance company?

You file a claim at the time of a contingency or medical emergency and you need financial assistance against the premiums you have paid to your insurance company.

Some important points to keep in mind while filing a health insurance claim

Your claim has to be a genuine one and it should not be a part of your exclusion.

For instance if you get injured while participating in an adventure course however you are looking for claim reimbursement from your insurer, they may deny it if they haven’t covered you against injuries caused due to adventure.

Don’t miss your renewal

If you fail to pay your premium on time there are higher chances that your policy may lapse and you will end up losing all the benefits of your health insurance plan.

Know the deductibles

Deductible is the minimum amount that one has to pay while filing an insurance claim. If your claim amount is less than your deductible then there is no use of filing a claim, or it means your claim is very minimal.

Do not delay your claim intimation

Whenever you plan a hospitalization or even when you are already hospitalized, please intimate your health insurance company to ensure your claim request does not get outdated.

Check your Sum insured limit

Be aware of your total coverage that is your sum insured limit. There is quite a possibility that your sum insured may or may not be sufficient to honor your claims. Some insurance policies like my:health Suraksha has the benefit of sum insured rebound wherein your lost sum insured is reversed to ensure your claims are paid.

When should I file a claim?

First and foremost, you just can’t file an insurance claim! Like just because you have a minor headache or fever and you consulted the Doctor for some medicines this doesn’t mean you will file a claim. You are liable to file a claim as per the coverage offered to you by your insurer.

Overview of a health insurance claim process

Health Insurance claims can be broadly classified as planned claim or unplanned claim. When your Doctor has asked you to get hospitalized for a particular course of treatment or surgery you file a claim intimating your insurance company about your hospitalization so that they are aware about the medical expenses that they need to honor once you raises the claim. Another scenario could be when there’s an emergency health issue and you intimate as soon as you know about the situation.

  • In both the above cases you can file the claim by collecting a form from your Hospital filling it up

  • You need to attach pre required documents like a letter mentioned by your Doctor on what is the procedure of treatment and need for you to be hospitalized.

  • Once the insurer approves your claim your medical bills are directly paid to the hospital in case of a cashless request at network hospital or it gets later reimbursed to you.

How do I intimate my claim or register a claim with HDFC ERGO?

  • You just need to enter your registered e-mail ID, contact number or Policy number hereto register your claim online.

  • In a few simple steps and by just answering some questions you can intimate your claim to your health insurance provider.

What does the insurer do once they receive your claim intimation?

For honoring a health insurance claim your insure will first go through all the documents shared by you and ask your for additional documents if needed.

  • There could be a chance that you have filed a claim for a disease which is under your pre existing illness and shall be covered post completion of waiting period.

  • It could be a chance that your claim is pertaining to a permanent exclusion of your policy.

  • If your claim is approved, which means your documents are perfect and your claim is as per the policy coverage and within the sum insured limits your health insurance company approves the claim.

  • If your hospitalization happens at a network hospital then your bills are directly paid to the hospital.

  • In case of hospitalization taking place in a non network hospital, you get the reimbursement on submission of medical reports and bills as per the document list suggested by claims team.

Can I make as many numbers of claims I wish to?

Making lot many claims may not be a good idea in the long term as the insurer will see you very susceptible to fall sick or make claims and which may probably lead to rise in premium for the coming years. However, this doesn’t mean that you don’t file claim when you need financial assistance. You may always file a claim when you are in need, after all that’s the whole purpose of securing your health with a health insurance company.

Things to look at while buying a health insurance plan from claims perspective

  • Claim settlement ratio, which evidently speaks about how many claims did the company settle for their customers.

  • The list of cashless network hospitals has to be huge to ensure you get atleast 1 or 2 cashless network hospitals in your locality. HDFC ERGO boasts 10,000+ cashless network hospitals to cater you endlessly.

  • These days insures ensure the claim is approved/rejected instantly so that you get a clarity on the same, HDFC ERGO approved 90% health cashless claims within 20** minutes isn’t that amazing?

  • With 1 crore+ happy customers we at HDFC ERGO aim at bringing smiles and ensuring we take care of you whenever you need us the most so that you can take it easy with us!

Hope the above article clarifies your several doubts about a health insurance claim and how it works!

*T&C apply. my:health Suraksha HDFHLIP20049V041920, UID No: D2HI417. **Average time taken for approval of our cashless health claims is less than 20 minutes. Based on the data from April 2019 to September 2019. Subject to satisfactory submission of all relevant documents and information(s) to the Company. TAT for approval of pre authorization requests 60 minutes. Cashless hospitalization available only in HDFC ERGO network hospitals. Visit for your nearest network hospital"


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