Health Insurance Claim

A health insurance claim is a formal request from a policyholder to their insurance provider for compensation of medical expenses incurred during a treatment. Understanding the two primary types of claims, the respective procedures, and the most common reasons for rejection can help ensure a smoother, less stressful experience when facing a medical emergency.

Types of health insurance claims:

• Cashless claims:In a cashless claim, you can receive treatment at a network hospital (affiliated with your insurer) without having to pay the entire bill upfront. The insurance company settles the hospital bills directly. This is often the preferred and most convenient option, especially for emergencies, but you must still pay for non-covered charges or co-pays.
• Reimbursement claims:With a reimbursement claim, you can seek treatment at any hospital, regardless of its network status, but you must pay all medical expenses out-of-pocket first. After treatment and discharge, you submit the original bills and documents to the insurer for reimbursement. This process takes longer and requires more personal financial management.

The cashless claim process

1. Intimate the insurer:For planned procedures, inform your insurer or Third-Party Administrator (TPA) at least 48–72 hours beforehand. For emergencies, notify them within 24 hours of hospitalization.
2. Use a network hospital:Opt for a hospital on your insurer’s network list. The TPA desk at the hospital will handle much of the coordination.
3. Submit the pre-authorization form:At the hospital, present your health card and a valid ID. Fill out the pre-authorization form provided by the hospital’s insurance desk.
4. Await approval:The hospital will send the form to your insurer for approval. The insurer will review the documents and inform you and the hospital of their decision. If approved, the treatment proceeds.
5. Pay non-covered costs:At discharge, you will only need to pay for any expenses not covered by your policy, such as non-medical items or specific consumables.

The reimbursement claim process

1. Intimate the insurer:For both planned and emergency hospitalizations, inform your insurer as soon as possible, ideally within 24–48 hours.
2. Pay medical expenses:Settle all hospital bills directly at the time of discharge.
3. Collect all original documents:Gather all original bills, prescriptions, reports, and the discharge summary. Keeping a detailed, sequential record of all medical and pharmacy bills is critical.
4. Submit the claim:Download and accurately fill out the reimbursement claim form from your insurer’s website. Submit the form along with all collected documents to the insurer within the specified timeframe, usually within 30 days of discharge.
5. Receive settlement:The insurer will verify your claim and, upon approval, transfer the eligible amount to your bank account.