Health Insurance Claim Process

Types of Health Insurance Claims

After purchasing a health insurance policy, you can raise the following types of health insurance claims.

Cashless Claim

This type of claim facility allows you to receive cashless treatment at a network hospital. After your treatment, your medical bills will be directly settled by us as per the policy terms and conditions. For example;

Amit has a health insurance policy with a 5 lakh sum insured. One day he experiences severe stomach pain and gets diagnosed with appendicitis. His doctor recommends immediate surgery. His wife checks the insurer’s list of network hospitals and gets him admitted to the nearest one. At the hospital, Amit’s wife fills out the registration form and provides policy details at the TPA desk. The hospital sends a pre-authorisation request to the insurer including the estimated surgery costs.

Now, the insurer reviews the request and approves 1.8 lakhs (estimated costs of surgery and hospitalisation). At discharge, the hospital generates a bill of 2 lakhs and it directly gets settled by the insurance company.  However, the additional cost of 20,000 for non-payable expenses must be borne by Amit.

Reimbursement Claim

If you visit a non-network hospital for treatment, the initial medical costs are borne by you. Then, you receive reimbursement for these costs after filing a claim with supporting documents. For example;

Pallavi is diagnosed with a minor health condition which requires hospitalisation. She rushes to a nearby non-network hospital for treatment. Since cashless treatment is not applicable in non-network hospitals, she pays the bills upfront.

At discharge, she pays 1.5 lakh out of her pocket for medical expenses. She collects her discharge summary and hospital bills for the claim process. After discharge, she fills out the reimbursement claim form and attaches all the collected documents.

She submits it to her insurance company after 30 days of discharge. The insurer verifies the claim documents and approves the reimbursement amount of 1.4 lakh, deducting 10,000 for non-covered expenses. Within 15 to 30 days, the approved amount of 1.4 lakhs gets credited to Pallavi’s bank account.

Difference Between Cashless and Reimbursement Claims

The below table shows the difference between cashless and reimbursement claims based on different factors.

Steps for Medical Insurance Claim Procedure

To provide a better understanding, we have bifurcated the medical health insurance claim procedure into cashless reimbursement claims and accidental injuries and deaths.

Cashless Claim Process

Cashless hospitalisation is one of the best features of health insurance. It serves your purpose and gives you a financial cushion in a difficult time. Our cashless claim process is simple and has the following steps:

• Get admitted to the nearest network hospital
• For identification purposes, show the health card issued by your insurer
• Post verification of your identity, the hospital will give you a pre-authorization form
• Complete the form and submit it at the TPA desk
• The network hospital will forward the form to your insurance provider
• The claim management team of the insurance company will review your pre-authorisation request and the submitted documents.
• After reviewing, they’ll approve your claim according to your policy terms and conditions.
• Your insurance provider will directly settle the bill with your network hospital.

Reimbursement Claim Process

At times, it happens you have to be admitted to non-network hospitals for different reasons. But, do not worry! All you can do is follow these steps for the reimbursement process in health insurance:

• Inform your health insurance provider about your hospitalisation at a non-network hospital
• Receive treatment at the hospital
• During discharge, pay the bill upfront and collect related documents
• Fill out the claim form and attach the required documents
• The claim management team will review your submitted documents and send their approval as per policy terms and conditions.
• After the approval, you will receive the claim amount.

Claim Process for Accidental Injuries

A medical emergency can knock on the door anytime. We understand the urgency of hospitalisation; that's why we keep the medical insurance claim process for accidental injuries and death simple. The foremost step you’re supposed to take while filing a claim for accidental injuries is to inform your insurance provider about the accident. The next step involves submitting the claim form along with vital documents including;

• Police FIR
• Medical certificate issued by the hospital/doctor
• A discharge form issued by the hospital/doctor
• Report issued by a medical examiner
• Medical documents issued by the hospital/doctor

Note: Show the health insurance card provided by us to get cashless benefits at our network hospitals.

Claim Process in Case of Accidental Death

In case of severe injuries leading to the accidental death of the policyholder, the nominee must fill out the former’s death claim along with the following documents;

• Police FIR in case of unnatural death
• Post-mortem report
• Original policy documents
• Death certificate
• Medical Certificate and hospital records
• Age proof of the insured
• Cremation certificate and employer certificate

How Long Does it Take to Process a Health Insurance Claim?

At Care Health Insurance,  we will directly pay your bills for the cashless claim process once you get discharged from the hospital after approval from the claim management team. For medical claim reimbursement, you have to submit the required documents within 15 days of getting discharged from the hospital. Our claim management team will approve your claim within the stipulated period.

>> Check: Health Insurance Claim Settlement Ratio

Documents Required for Health Insurance Claim Process

Below is the list of documents that are required to file a claim:

• Duly filled and signed claim form
• Doctor's prescription and referral letter
• Diagnostic tests and medical reports
• Original bills, receipts, and discharge papers from the hospitalisation
• Original bills from pharmacy/chemists
• Police FIR in case of personal accident
• Policy copy including policyholder name, contact number, nature of the illness, address, and other required information

Note: Post-mortem report and death certificate is only required in case of accidental death.

How to Track the Status of Your Health Insurance Claim?

You can check the status of your using the online facility. If you have opted for a policy from us, you need to visit the official website and track the status by entering relevant details. It is applicable in the case of checking the reimbursement claim or cashless claim status.

Top Reasons for Health Insurance Claim Rejection

Here are the major reasons for the rejection of health insurance claims:

• Not revealing pre-existing disease at the time of buying the policy
• Filing claims for treatments excluded from the policy
• Not raising a claim during the defined period
• Raising a claim during the waiting period
• Fake claims
• When the claim amount exceeds the policy sum insured

Tips to Avoid Claim Rejection

Filing an insurance claim can be stressful and rejection can make it even more challenging. To enhance your chances of claim approval, follow these essential tips to avoid common mistakes that lead to claim rejections;

• Avoid hiding any information such as any pre-existing condition at the time of buying a policy.
• Inform your insurer about your planned or emergency hospitalisation with a definite time.
• Carefully read the inclusions, exclusions, waiting periods, claim procedures, features and benefits of your policy before filing a claim.
• Submit all the required documents including medical reports when filing a claim.
• Get admitted to a network hospital to avail cashless claim facility.