Health insurance acts as a financial safeguard during medical emergencies, making it essential in light of the rising healthcare costs. To maximise the benefits of your insurance policy, understanding the process of filing a health insurance claim is vital. A health insurance claim involves the policyholder requesting the insurer to cover medical services and benefits specified in their policy. Essentially, it is the procedure to receive financial reimbursement from the insurer for medical expenses incurred. Continue reading to learn how to make a health insurance claim.

Types of Health Insurance Claims

Health insurance plans are designed to provide financial support for healthcare services. To access this support, policyholders must file a health insurance claim. There are two main types of health insurance claims:

1. Cashless Claims
   In a cashless claim, the insurance company directly settles medical bills with the hospital. To avail this benefit, the insured must be hospitalised at a network hospital affiliated with the insurer.
2. Reimbursement Claims
   With reimbursement claims, the policyholder pays for hospitalisation expenses upfront and seeks reimbursement from the insurer later. This type of claim can be made at both network and non-network hospitals.

Steps to Claim Health Insurance 

Here’s how to claim health insurance benefits via both cashless and reimbursement claims.

Cashless Health Insurance Claim Procedure

Here are the steps for filing a cashless claim under your health insurance policy.

• Get admitted to one of the network hospitals affiliated with your insurance provider and get in touch with the hospital’s insurance helpdesk.
• Present the health insurance card provided to you by your insurer for identification.
• The hospital will verify your identity and provide you with a pre-authorisation form for cashless treatment.
• Complete the pre-authorisation form and submit it at the insurance desk.
• The network hospital will forward the pre-authorisation form to your health insurance provider.
• The insurance provider will review your pre-authorisation request as well as the submitted documents before approving your cashless claim as per the terms and conditions of your health insurance policy. Some insurers may also assign a field doctor to facilitate the cashless claim authorisation process.
• At the time of discharge, settle any medical expenses that are not covered by your health policy.
• Your insurer will directly pay the claim amount to the hospital according to the terms and conditions of your plan.

Reimbursement Health Insurance Claim Process

Here are the steps for filing a reimbursement claim under your health insurance policy.

• Inform your health insurance provider about your hospitalisation as soon as possible.
• Receive treatment at the hospital.
• Upon discharge, pay the entire hospital bill and collect all related documents.
• Submit all the necessary documents to your insurer.
• The insurance provider will review the submitted documents before processing the claim as per the terms and conditions of your health policy.
• Once your claim is approved, the claim amount will be reimbursed to you.

Documents Required to Claim Health Insurance

You’ll need to submit the following documents while filing a health insurance claim.

• Health insurance ID card
• A completely filled-in claim form
• All consultation papers provided by the doctor
• Hospital bills with payment receipts
• All diagnosis and investigation reports (like X-rays, CT scans and blood reports)
• FIR and/or Medico Legal Certificate (in case of accidents)
• Discharge summary
• Pharmacy invoices with respective payment receipts and prescriptions
• Any other relevant documents requested by the insurer

Types of Hospitalisations You Can Claim Health Insurance for

A health insurance claim can be raised for two types of hospitalisations:

• Emergency Hospitalisation: This type of hospitalisation occurs unexpectedly, usually due to an accident or sudden illness that requires immediate medical attention. In such cases, the insured's family must contact the health insurance provider within 24 hours of the patient's admission to the hospital.
• Planned Hospitalisation: This type of hospitalisation is pre-arranged and typically required for treating a diagnosed illness or a medical condition. The policyholder must inform the insurer about the planned hospitalisation a minimum of 48 hours prior to the actual admission to the hospital.

Tips for Successfully Filing a Health Insurance Claim

For successfully filing a health insurance claim, keep the following points in mind:

• Notify your insurance company about your hospitalisation as soon as you are admitted.
• Ensure the cashless pre-authorisation form is filled in correctly to avoid denial.
• Submit reimbursement claims within 30 days from the hospital discharge date.
• Be prepared to pay for non-payable items out of pocket.
• Review the policy’s sub-limits, exclusions and other terms to understand your coverage.
• For post-hospitalisation expenses, submit all required documents within the time frame specified by the insurer.

Can a Health Insurance Claim be Rejected?

There are several instances wherein a health insurance claim may be rejected by your insurance provider. Some common reasons for claim rejection include:

• Filing a claim for treatments or illnesses not covered by the policy
• Failing to disclose pre-existing conditions when purchasing the policy
• Not submitting the claim within the required time frame
• Submitting fraudulent claims
• Raising a claim during the policy's waiting period
• Claiming an amount that exceeds the policy’s sum insured
• Attempting to claim under an expired health insurance policy

Conclusion

To fully benefit from your health insurance policy, it’s essential to understand the process of filing a claim. By following the correct procedures for either cashless or reimbursement claims, and by ensuring you submit all necessary documents promptly, you can navigate the claims process smoothly. Keep in mind the different types of claims and hospitalisations covered, and always be aware of your policy’s terms and conditions to avoid common reasons for claim rejection. With this knowledge, you can confidently manage your health insurance claims and ensure you receive the financial support you need when it matters most.
 

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