A step-by-step process to make health insurance claim

Get a detailed guide on the health insurance claim process and get your claims settled smoothly.
A step-by-step process to make health insurance claim
3 mins
30 July 2023

Health insurance policies provide financial protection against unexpected medical expenses. It works as a great asset to tackle medical emergencies. To reap maximum benefit from your health insurance policy, it is important to know the process to make health insurance claims. You get two options to settle health insurance claims: cashless and reimbursement claim settlement.

Read on to know about the two types of health insurance claims in detail. Also, get to know the documents required to file a claim, and tips to avoid health insurance claim rejections.

How to make a health insurance claim?

The first thing to do when making a health insurance claim is to inform the insurance company as soon as possible. It is important to adhere to the time limit specified in the policy for filing a claim. The insurer’s representatives guide you through the claim process on documents you need to submit and how to fill out the claim form. If you do not inform the insurer in time, your health insurance claim may get rejected.

Types of health insurance claims

Here are the two ways that you can file a health insurance claim.

Cashless claim settlement

In a cashless health insurance claim, the insurer directly deals with the network hospital. Here you only need to get treated or admitted at any of the nearest network hospitals and inform the insurer. You need to give a claim intimation within 48 hours of emergency admission or 72 hours before planned hospitalisation. Also, contact the insurance desk at the hospital immediately after getting admitted. Following which the admin will send a pre-authorisation form, claim form, and necessary documents to the insurer.

If you already got the pre-authorisation form approved by the insurer, the process will start sooner. Upon reviewing the documents, insurer will approve the claim if it is within the policy terms and conditions and settle the bills directly with the network hospital.

Reimbursement claim settlement

This facility enables you to choose any of your preferred hospitals to get the treatment. The only difference here is that you will need to clear the hospital bills first and then claim for reimbursement. You need to give a claim intimation to the insurer within 48 hours of emergency or three days before planned hospitalisation for the reimbursement claim process.

After getting discharged, submit the hospital bills, discharge summary, doctor’s prescriptions, and reports to the insurer. You may need to submit a few documents as required or asked by the insurer. After reviewing the documents and verifying the claim’s authenticity, the insurer will reimburse the claim amount within 10-15 working days. In some cases, it may take up to 30 days. This depends on the insurer and their policy terms and conditions. You will receive the claim amount in your registered bank account.

Also, check the claim settlement ratio in health insurance.

What documents do I need to file a health insurance claim?

You mainly need to submit the documents if filing for a reimbursement claim. In case of cashless claim settlement, the network hospital takes care of everything.

Here is a list of documents that you need to submit when making a health insurance claim.

Filled claim form (both A and B)

You can download the claim form from the insurer’s website. You will also get it at the hospital’s insurance desk.

Medical bills and reports

You will need to provide all original medical bills and reports from the hospital.

Discharge summary

This document has the details of the treatment taken and the diagnosis given.

Prescription and medical certificate

A prescription from the treating doctor and a medical certificate confirming the need for hospitalisation.

Identity proof

You need to share valid identity proof like Aadhaar Card, passport, voter ID, etc.

Things to consider while applying for a health insurance claim

Here’s what you need to consider when applying for a health insurance claim. The following points will help you speed up the claim process and get your claim settled easily.

Make the claim in time

You need to inform the insurer about the claim within the specified time in your policy. Avoid any delays. For reimbursement, you need to submit the documents to the insurer within 15 days of getting discharged.

Accuracy of information

Ensure you provide all the information in the claim form accurately. Also, share the correct documents with the insurer. Any incorrect information can lead to the rejection of the claim.

Adequate coverage

Make sure that you have adequate coverage under your health insurance policy to meet the medical costs incurred.

Avail of cashless facility

If the hospital has a tie-up with your health insurance company, opt for a cashless facility. The hospital will then take care of the claim settlement directly with the insurance company.

Tips to avoid health insurance claim rejections

Here are some tips that you must consider to ensure your health insurance claim gets accepted easily.

Keep the policy up to date

Make sure to pay the health insurance policy premiums on time to ensure that the policy remains in effect. Also, see that your policy has not expired.

Disclose all medical information

Ensure that you disclose all your medical history, pre-existing conditions, etc. in the health insurance proposal form.

Adhere to terms and conditions

Read the policy terms and conditions carefully. It mentions the time limit for filing a claim, the deductible amount you may have to pay, etc. Also, conditions for making a health insurance claim for a specific illness, if any.

Seek pre-authorisation

Before undergoing any treatment, seek pre-authorisation from the insurance company. This will ensure that the claim does not get rejected later.

Steps to check the status of a health insurance claim

You can check the status of a health insurance claim in the following ways:

Check health insurance claim status online

Most insurance companies allow you to check the status of your claim online through their website or mobile app. You need to enter your policy number or claim reference number to check the status.

Call the insurer

You can call the insurer’s customer care helpline and provide your policy number or reference number to check the status of your claim.

Visit the insurance branch office

To check the health insurance claim status offline, you can also visit the insurance company’s branch office.

Making a health insurance claim can seem like a daunting task, but with the above information, you can ensure a smooth process. The health insurance claim process varies depending on the type of claim filed, and the documents required. You should ask your insurance company about the claim process in detail when buying the health insurance policy. It will help you make health insurance claims easily.

Frequently asked questions

When can I make a health insurance claim?

You can make a health insurance claim when you get hospitalised for medical treatment. You can make the claim in two types, either opt for a cashless claim or a reimbursement claim. For a cashless claim, you need to seek treatment at a network hospital. For reimbursement claims, you can choose any of your preferred hospitals.

Can I make a yearly claim for health insurance?

Yes, most health insurance policies allow policyholders to make a yearly claim. However, the limit for a claim amount may differ depending on the policy. Typically, policyholders can claim up to a limit each year, and the insurer will not payout anything above that limit.

What percentage of medical coverage can I claim?

The percentage of medical coverage that you can claim depends on the policy's terms and conditions. Most policies cover medical expenses ranging from 70% to 100% of the total expenses incurred. You will find the total limits for claims defined explicitly in the policy agreement.

When does a claim get rejected?

Claims can get rejected for various reasons: non-disclosure of pre-existing medical conditions, delay in filing the claim, or unapproved treatment providers. Some other reasons include medical procedures taken outside of the policy's specified coverage and policyholders under/over-insured. Providing inaccurate or incomplete information while filing the claim can also lead to claim rejection. It is important to adhere to the policy terms and conditions and provide all relevant information when making a claim to avoid rejection.

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