Health Insurance Claim Process

Many people buy health insurance plans from insurance companies in India without taking into account the efficacy and ease with which the companies settle their customers’ claims. Though there is nothing complex about the claim settlement process, a lot depends on whether the policyholders had opted for cashless claims or reimbursement of the expenses on hospitalization and consequent treatment.

Types of Health Insurance Claims

To understand the process, it is important to understand the types of health insurance claim available in the country. There are two ways that policyholders may adopt to claim a health insurance policy. These include:-

Cashless Claims

As per this type of health insurance claim, the insurance company settles the hospitalization bills with the hospital directly. However, to avail this benefit it is important that the amount of bill must not exceed the total sum assured amount and that the policyholder must be hospitalized only at a network hospital.

Reimbursement Claims

This is a different kind of settlement process in which the policyholder pays for the hospitalization expenses and then seeks reimbursement from the insurance company post-discharge from the hospital. The reimbursement facility is available at both the network hospitals and those outside the network.

Health Insurance Claim Process For Cashless Claims

If treated at one of the network hospitals, policyholders need not make any upfront payments for the treatment they had sought. The insured will not be required to bear the burden of the medical bills as the insurance proposal agreement contains details of acknowledgement by both the health insurance provider and the hospital in which the policyholder is being treated. In addition, the cashless benefit is pursuant to the approval of the third-party administrator (TPA).

All that the policyholder has to do is to show the health card issued by the health insurance company at the particular hospital for treatment as a proof of having bought the relevant health insurance plan along with a valid government ID.

Health Insurance Claim Process In Case of Policy Reimbursement

One of the benefits of buying health insurance is that the policyholder can get the expenses on treatment reimbursed. The reimbursement is made as per the terms and conditions of the insurance agreement signed between the insurance company and the policyholder. The total amount of expenses minus the exclusions are credited to the bank account of the insured after the insurance company is satisfied with the validity of the invoice raised by the policyholder post-discharge.

Before we proceed to explain the claim settlement process, let us look at the following conditions necessary to avail the health insurance claim. They are:-

1. Remember to fill in all the details in the health insurance claim form lest the authorization process may be cancelled;
2. The policyholder must file the health insurance claim form within a month of discharge from the hospital;
3. It is mandatory for the policyholder to submit all the relevant documents within 30 days from the date of discharge;
4. The policyholder would be required to make payment for the non-payable items post-discharge.

List of Documents Required for Health Insurance Claim Reimbursement

While most policyholders are aware of the insurance buying process, not many people realize the need to pay similar attention to the health insurance policy claim settlement or reimbursement process. While claiming for the necessary health insurance cover, policyholders would be required to submit the following documents. These include:

1. Patient discharge card issued by the hospital
2. In-patient hospitalization bills signed by the policyholders for validation purposes
3. Prescriptions recommended by the doctor in charge
4. Medical store bills
5. Invoice for implants if used during the surgery
6. Claim forms self-attested by the concerned policyholder
7. Valid investigation report issued by the hospital or treatment facility
8. Any consumable or disposable item required for treatment and prescribed the doctor
9. Bill or receipt of fees paid to consult various doctors or medical specialists;
10. A copy of the health insurance policy document and a copy of the ID card issued by the third-party administrator (TPA)
11. Any other relevant documents as requested by the TPA
12. Medico-Legal Certificate (MLC) or a copy of the FIR filed in the event of any road accident
13. A cancelled cheque of the bank in which the policyholder wishes to get the reimbursement amount credited.