Health Insurance Claims Process – A Step-by-Step Guide

Posted on: Nov 28, 2019 | 3 mins | Written by: HDFC ERGO Team

Health Insurance Claims Process – A Step-by-Step Guide

Healthcare costs are rising by the day, and a medical procedure can cause financial distress if you are not prepared for it. Hence, covering yourself and your loved ones under medical insurance for those uncertain times is wise. And when you buy this insurance product, make sure you go through the policy documents and familiarise yourself with the health insurance claims process to avoid hassles during medical emergencies.

Insurance companies allow policyholders to make two types of claims against their health plan - cashless and reimbursement. Let's understand each of these health insurance claims processes in detail.

Types of Claims in Health Insurance

There are two modes of claims in health insurance - cashless and reimbursement.

1. Cashless claim:

This type of health insurance claims process works when you opt for a medical procedure in a network hospital (i.e., a hospital with which your insurer has a tie-up for cashless hospitalisations) of your insurance provider. In this case, the insurer will settle your bills directly with the hospital. Hence, the claim settlement process requires minimum documents and is quite hassle-free.

2. Reimbursement claim:

If you choose a non-network hospital for your medical procedure, you must settle the hospital bills from your pocket and then file a reimbursement claim with the insurance company. For this, you must submit original bills and receipts from the hospital to the insurance company. The entire claim settlement process can take around 3-4 weeks.

Steps to File a Cashless Claim in Health Insurance

The following are the steps to file a cashless claim for health insurance.

Step 1: Find a network hospital

Choose a network hospital for the medical procedure. You can find the list of network hospitals in the policy documents.

Step 2: Intimate the insurance company

If it is a planned procedure, inform the insurance company at least 3 days in advance and get their approval. For medical emergencies, you must inform the insurer within 24 hours of hospitalisation.

Step 3: Fill out the pre-authorisation form

Obtain the pre-authorisation form from the TPA desk at the hospital or the insurance company. Fill it out correctly and submit it at the hospital's TPA desk with your ID proof and health e-card.

Step 4: Claim Verification

The insurance company will verify the claim and settle your bills directly with the hospital.

Steps to File a Reimbursement Claim in Health Insurance

If you opt for a medical procedure at a non-network hospital, here's how you can file a health insurance reimbursement claim.

Step 1: Inform the insurance company

You must inform the insurance company about your hospitalisation at least 3 days in advance. If it is a medical emergency, inform them within 24 hours of hospitalisation.

Step 2: Obtain the claim form

Collect the claim settlement form from the insurance company or TPA desk at the hospital.

Step 3: Collect the documents

Once you get discharged from the hospital, settle the medical bills from your pocket and collect the discharge summary and other bills and receipts from the hospital.

Step 4: Submit the Claim Form & documents

Fill out the claim settlement form correctly and submit it to the insurance company along with the following documents:

• Your health e-card

• Your photo ID proof

• Proof of address

• Original discharge summary

• Doctor's prescription recommending hospitalisation

• Doctor's consultation slip and prescriptions for diagnostic tests

• Certificate from the attending doctor

• Prescription for medicines and original pharmacy bills

• Diagnosis reports of X-rays, blood tests, etc.

• Other original receipts from the hospital

• Breakup of the hospital bill

• Ambulance receipt, if applicable

• FIR, in case of an accident

You must arrange the documents either date-wise or in the prescribed format. Also, remember to take photocopies of all the documents before submitting them to the insurance company. The insurance company will also need a cancelled cheque of your bank account for crediting the proceeds of your reimbursement claim.

Step 5: Claim Verification and Settlement

The insurer will check the claim form and supporting documents before approving your claim. If everything looks fine, they will approve the claim and transfer the claim amount to your bank account.

In case of missing documents and incorrect information about age, smoking habit, annual income, etc., the insurer may reject your claim altogether.

Things to Consider While Making Health Insurance Claims

The following are some important factors to consider when making health insurance claims.

1. Health insurance validity:

Check if your health insurance policy is valid. The insurance provider will not entertain your claim if your health insurance has expired. So, whether you have an individual or family health insurance policy, make sure the plan is valid before your file a claim.

2. Policy inclusions and exclusions:

This is important as you can't file a claim for a condition that is not part of your health plan or is excluded from it altogether. Even if you file one, the insurance company will reject it. For example, if you file a claim for a critical illness that is not covered under your critical illness insurance policy, the insurer will not entertain your claim.

3. Waiting period:

Before you file a health insurance claim, make sure the initial waiting period is over. Also, some insurance policies have a longer waiting period for pre-existing conditions, so remember to check the same before filing a claim.

4. Documents required:

When filing a health insurance claim, you must submit certain documents supporting your claim, such as the original discharge summary, hospital bills, doctor's prescriptions, etc. Check the documents you must submit to your insurance provider and make sure you submit them all to avoid claim rejection.

5. Claim amount:

If the claim amount is small and affordable, you can choose to pay the same from your pocket and enjoy no-claim benefits on your healthcare plan.

Conclusion

To summarise, when buying health insurance, check the health insurance claims process to avoid any confusion later. Most importantly, inform the insurance company well in time about your claim, as late intimation can lead to claim rejection. Also, submit the claim form and supporting documents within 15 days of getting discharged from the hospital or as stated in your health insurance policy documents.

Disclaimer: The above information is for illustrative purposes only. For more details, please refer to the policy wordings and prospectus before concluding the sales.

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