How to File Health Insurance Claim?

A health insurance claim is a formal request made by a policyholder or healthcare provider to an insurance company for reimbursement of medical expenses incurred due to treatments, hospitalizations, surgeries, diagnostic tests, or other healthcare services provided to the policyholder. This process allows the policyholder to recover some or all of the medical expenses covered under their health insurance policy, helping to alleviate the financial burden of healthcare costs. Health insurance claims are essential in ensuring that the policyholder has access to necessary medical care without facing significant out-of-pocket expenses, as long as the services are in line with the terms, conditions, and coverage specified in the insurance policy.

Types of Health Insurance Claims:

Here are the two main types of health insurance claims designed to cover your medical expenses seamlessly.

1. Cashless Claim

With cashless claims, you can visit a network hospital for treatment, and the insurance company handles the payment directly with the hospital. Your medical expenses will be covered as per your policy. You only need to provide your policy details to the hospital, and the insurance provider will manage all the paperwork and formalities for you.

2. Reimbursement claims

With reimbursement claims, you pay for your medical expenses upfront and then submit the bills to your insurance company. The insurer will review the bills and reimburse you for the amount covered under your policy. This process can take some time, so it's a good idea to regularly check the status of your claim to stay informed about your reimbursement.

Claim Process - Step-by-Step Guide

Here’s a step-by-step guide to the health insurance claim process:

1. Cashless Claim Process

Step 1 : Upon being admitted to a network hospital affiliated with your insurance provider, kindly reach out to the hospital’s insurance helpdesk for efficient guidance and support throughout the claim process.

Step 2 : Notify your insurance company about your hospitalization at the earliest. For planned procedures, ensure to inform them at least 3 days in advance. In case of an emergency, please inform them within 24 hours of admission.

Step 3 : Collect the pre-authorization form from the Third-Party Administrator (TPA) desk at the hospital or your insurance company. Ensure that the form is filled out correctly and submit it, along with a valid ID and your health e-card, at the TPA desk at the hospital.

Step 4 : The insurance company will review your claim, and once approved, will directly settle the payment with the hospital.

Examples:

Mr. James holds a cashless claim policy. After sustaining injuries in an accident that require emergency surgery, the expenses for his treatment are covered under his policy. He provides his policy details to the hospital, and the insurance company directly settles the bills with the hospital.

2. Reimbursement Claims process

Step 1 : Notify your insurance company at least 3 days before a planned procedure or within 24 hours in the event of an emergency.

Step 2 : Obtain the claim settlement form from your insurance provider or the TPA desk at the hospital.

Step 3 : After discharge, ensure you collect the discharge summary, along with all relevant bills and receipts from the hospital.

Step 4 : Complete the claim form accurately and submit it to the insurance company along with all necessary supporting documents.

Step 5 : Once your claim is approved, the insurance company will pay you the claim amount.

Example:

Ms. Amy, however, has a reimbursement claim policy. After being diagnosed with a minor health condition that requires hospitalization for a few days, she pays for the hospitalization, room rent, medications, and other expenses upfront. Once her treatment is complete, she reaches out to her insurance provider, submits the bills, and receives reimbursement for the eligible expenses.

Documents Required for Health Insurance Claim

To make a health insurance claim, you may need to provide the following documents:

Proof of identity

Policy document

Medical reports related to your illness

Hospitalization papers, including dates

Medicine bills

Ambulance bills

Discharge papers

Any other treatment-related expenses