Health Insurance 246 views April 13, 2021

Paying your medical bills in case of a medical emergency can exhaust all your savings. A health insurance plan could be your perfect companion amid a medical emergency as it provides coverage against medical or hospitalization expenses. You only need to initiate the claim for your health insurance plan. To do the same successfully, you need to understand how health insurance claims work in the first place.

On this page, we will discuss the same to make things easier for you. Here, you can know the types of claims in health insurance, how to file claims, documents you will require, what needs to be done for pre-and post-hospitalization claims, OPD, Domiciliary hospitalization, etc. So, let’s start understanding the same!

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Types of Health Insurance Claims

Health insurance companies provide mainly two types of health insurance claims — cashless Claim and Reimbursement Claim processes. Policyholders can choose from these two options according to their convenience. We are providing details about both of them below. Please check!

Health Insurance Cashless Claim Process

As the name of this claim process suggests, policyholders don’t need to pay any cash while getting treatment in one of the tied-up hospitals (network hospitals) with the respective insurer. When you choose this type of claim process, you only need to get hospitalized in a network hospital. The insurer will directly settle the hospital bills with the network hospital according to your policy’s terms and conditions.

The cashless claim process can be further divided into two types — Planned Hospitalization and Emergency Hospitalization. To know more, you can check the below table.

Planned HospitalizationEmergency Hospitalization
In case of planned hospitalization, you should inform the insurer well within 2 to 4 days before the hospitalization to get a successful claim. (Time frame to inform tends to change from one insurer to another)In case of an accident or an illness that needs urgent treatment, you will need to undergo emergency hospitalization. In such a case, you should inform the insurer within 24 hours of getting hospitalized in a network or non-network hospital.

Steps to Get Cashless Claim Process at Network Hospitals

You will need to follow the steps mentioned below to get a cashless claim at network hospitals. Please check!

Step 1: Get hospitalized at the nearest or convenient network hospital.

Step 2: After hospitalization, you will need to prove your identity with your insurer’s health card along with a photo ID (Aadhar Card, Driving Licence, PAN Card, etc.)

Step 3: The network hospital will send the pre-authorization to the respective insurer.

Step 4: The insurer will review the details to approve your cashless claim accordingly. After approval, the insurer will settle the bills with the network hospitals as per the terms and conditions mentioned in your policy document.

Note: Remember to inform the insurer about the hospitalization as per the stipulated time frame to get a successful claim.

Health Insurance Reimbursement Claim Process

With this type of claim process, the policyholder needs to pay the bills by himself/herself, and the insurer will reimburse the coverage amount. So, in case your cashless claim gets rejected at a network hospital or you are getting treatment in a non-network hospital, the reimbursement claim process can help you.

To file a reimbursement claim process, you will need to pay the medical expenses upfront and submit the following documents to your insurer (after getting discharged) to get the reimbursement amount into your bank account.

  1. A properly-filled claim form along with your policy number
  2. Medical certificate
  3. Discharge summary or card from the hospital in original
  4. All bills and receipts incurred towards the treatment
  5. Investigation reports such as MRI, X-ray, Blood Reports, etc.
  6. Bank account details of the policyholder
  7. FIR or Medico-Legal Certificate (In case of an accident)
  8. NEFT details

Your insurer will assess these documents. Once the claim is verified and found legitimate, the insurer will reimburse the amount to your bank account within a fixed time that varies from one insurer to another.

Note: To get a successful reimbursement claim, you should file within 7 to 15 days after getting discharged from the hospital. 

How Do Pre-and Post-Hospitalization Claims work?

Health insurance plans also provide coverage against expenses that happen before policyholders get hospitalized (Blood test, Urine, X-ray, etc.) and after getting discharged from the hospital (Follow-up tests, Physiotherapy, etc.). This period generally ranges from 30 to 90 days. To get a claim for pre-and post-hospitalization expenses, you will need to use the reimbursement method. You will need to pay the expenses from your pocket and submit the required documents later to get the reimbursement.

Note: Do remember the time limit for filing your post-hospitalization claim stands within 15 days after 60 or 90 days from the date of discharge. 

How Do Claims Work in Domiciliary and OPD Treatment Coverage

A few Health insurance plans also provide coverage for outpatient treatment (where you don’t need to get hospitalized for treatments like Root canal treatment) and domiciliary treatment ( treatments that can be taken even when individuals are at home). Similar to the pre-and post-hospitalization claim process, you will need to pay upfront and submit the necessary documents to get the reimbursement from your insurer.

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