Introduction

We take health insurance to protect against unexpected medical emergency for our self and family. It is necessary to know how to proceed with your health insurance claims; whether it emergency or planned hospitalization. It is important to know health claim procedure which will help you in timely claim approval, smooth settlement and fight if your health claim is denied or delay. Let us understand how does health insurance claims works!

What is a Health Insurance Claim?

A health insurance claim is a formal request made by a policyholder to the insurance company for reimbursement or direct settlement of medical expenses covered under the policy. There are two primary types of health insurance claims:

• Cashless Claims: The insurance company directly settles bills with network hospital.
• Reimbursement Claims: The policyholder pays upfront and later gets reimbursed by the insurer.

Understanding the step-by-step claim process can help prevent delays and denials.

Types of Health Insurance Claims

1 Cashless claims

A cashless claim means the insurer settles the hospital bills directly, provided the treatment occurs at a network hospital. This eliminates the need for upfront payments.

2 Reimbursement Claims

In reimbursement claims, the insured pays for the treatment out-of-pocket and then submits a claim to recover the expenses from the insurer.

How to File a Cashless Health Insurance Claims?

Step 1: Choose a Network Hospital

To avail of a cashless claim, get admitted to a hospital that is part of the insurance provider’s network hospitals. The list of network hospital is provided with health insurance policy or available on Insurance Company’s website.

Step 2: Inform the Insurance Company

Intimate the insurance company (In-house) or Third-Party Administrator (TPA) about the hospitalization as soon as possible. Many insurers have a time limit (within 24 hours for emergencies and 48 hours for planned hospitalizations). Delay in intimation may make claim process tedious resulting in clarification from policyholder for delay.

Step 3: Submit Pre-Authorization Request

The hospital will submit a pre-authorization request form to the insurer, including details about the treatment and estimated expenses. Pre-authorization is approval for medical treatment of patient.

Step 4: Approval from Insurer

The insurer will verify the details and grant pre-authorization approval, allowing the hospital to proceed with the treatment without asking for upfront payment. Pre-authorization approval amount will be less than estimated bill submitted by hospital.

Step 5: Hospitalization and Treatment

Once approved, the insured can receive treatment without worrying about hospital bills. The insurance company will assess medical treatment and may ask clarification if required from hospital. The insurance company will directly settle the bill with the hospital.

Step 6: Claim Settlement

Hospital will submitted all medical treatment records, discharge certificate, hospital bills to insurance company for assessment and verification of documents. The final bill is settled without the insured having to pay.

How to File a Reimbursement Health Insurance Claim?

Step 1: Pay Hospital Bills

In case of treatment at a non-network hospital, the insured must first pay the medical expenses out-of-pocket.

Step 2: Collect Necessary Documents

Insured gather all essential documents such as:

• Hospital bills and receipts
• Doctor’s prescriptions
• Discharge summary
• Diagnostic reports
• Insurance claim form
• Cancelled cheque for reimbursement

Step 3: Submit the Claim to the Insurer

Send the collected documents to the insurance company within the prescribed timeframe, typically within 30 days of discharge.

Step 4: Claim Assessment

The insurer will review the claim, verify documents, if any clarification needed will communicate with insured and process it for reimbursement.

Step 5: Claim Approval and Reimbursement

After reviewing all medical records and bills claim amount is approved and claim amount is credited to the insured’s bank account.

Common Reasons for Health Insurance Claims Rejection

Despite following the process, some claims get rejected. Here are some common reasons:

• Incomplete documentation of health insurance claims
• Exceeding time limits for claim submission
• Treatment for excluded conditions
• Pre-existing disease waiting period not completed
• Hospital not recognized under policy terms
• Non-disclosure of existing diseases

We have details article on “10 steps to avoid your Health Insurance Claim Rejection”

Tips to Ensure Smooth Health Insurance Claims

• Always inform the insurer about hospitalization immediately.
• Choose a network hospital to avoid reimbursement hassles.
• Check policy coverage, exclusions, and limits beforehand.
• Keep copies of all medical records and bills.
• Submit claims within the stipulated time frame.
• Read the policy terms and conditions carefully.

Documents Required for Health Insurance Claims

• Duly filled claim form
• Hospital bills and discharge summary
• Doctor’s prescription and treatment details
• Diagnostic test reports
• Pharmacy bills with doctor’s prescription
• Insurance policy details
• Bank details for reimbursement

Health Insurance Claim Processing Time

• Cashless claims are usually processed within a few hours to a day.
• Reimbursement claims may take 7-15 days, depending on submission of all documentation and verification.

What to Do If a Claim is denied?

If your health insurance claim is rejected:

1. Review the reason for rejection mentioned in the insurer’s response.
2. Rectify errors and submit missing documents if applicable.
3. File a dispute or appeal with the insurer.
4. Approach the Insurance Ombudsman if disputes remain unresolved

Will discuss health claim denial in detail in another article.

Conclusion

Filing a health insurance claims correctly ensure you get the financial support you need without unnecessary stress. Whether opting for a cashless claim or reimbursement, knowing the process, maintaining proper documentation, and following the insurer’s guidelines can help prevent delays or rejections. Stay informed, read your policy carefully, and take timely action to secure your health insurance benefits hassle-free!