Health Insurance Claims Process

Claiming medical insurance benefits can be a complex process. Here's all you should know about cashless mediclaim procedure and making health insurance claims using the hospital bills and documents.

By V Saravana Kumar  • 8 min read

Health Insurance Claims Process

The purpose of taking a health insurance or a mediclaim policy, as it is commonly known, is to meet your family’s emergency medical expenses. This is where making a claim to get the insured money plays an important role. Understanding the technicalities of making a health insurance claim is vital, because even a small misstep might lead to rejection of the claim. So, read through this article to get a complete understanding of the insurance claims process.

What is a health insurance claim?

It is a request submitted by a health insurance policyholder to the insurance company for a payout towards the medical expenses borne by him/her. It can either be done at the time of getting hospitalised for medical treatment, or after being discharged from the hospital.

Types of health insurance claims

There are two ways to make a health insurance claim. They are:

Cashless claim: In a cashless mediclaim policy, the policyholder can apply for the claim amount right at the time of hospital admission. The insurance company settles all the bills to the hospital, and the policyholder need not spend anything. But, this facility will be available only at those hospitals that are a part of the network hospitals having a tie-up with the insurance company.

Reimbursement claim: Under reimbursement claim, the policyholder has to bear the hospital expenses himself, and then apply for the reimbursement of the amount spent to the insurance company. He needs to submit all documents including discharge summary, prescriptions, lab reports and other bills as proof along with the claim application. This facility can be availed at both network hospitals and non-network hospitals.

How to claim medical health insurance

Here’s what a policyholder needs to do while making a health insurance claim:

For cashless mediclaim:

  • In case of a planned hospitalisation, the insurance company needs to be intimated about it one or two days in advance. If it is an emergency, the intimation should be sent within 24 hours of hospitalisation.
  • Most health insurance policies are managed by Third Party Administrators (TPA) who act as the bridge between the health insurance companies and hospitals. The details about hospitalisation for treatment should be sent to the TPA at the time of admission.
  • The insurance company and TPA will inspect the documents and check if the policy covers the particular treatment. If everything is within the terms of the policy, they will send an approval to the hospital.
  • At the time of discharge, the hospital will send the insurance company a consolidated bill along with all the supportive documents, to claim the money for the treatment.
  • In case of pre-existing illnesses, you will have to wait two to four years before making the claim depending on your health insurance plan.

For reimbursement claim:

  • In this case too, it is mandatory to inform the insurance company as well as the TPA about the hospitalisation.
  • At the time of discharge from the hospital, the policyholder has to pay all the bills to the hospital and get receipts for them.
  • These payment receipts should be submitted to the insurance company and the TPA, along with all the supporting documents such as duly completed claim form, discharge summary issued by the hospital and signed by the treating doctor, and prescriptions of tests and drugs.

Documents required for making a medical insurance claim

The following are the documents that should be submitted while making a health insurance claim:

  • Copy of the health insurance ID card
  • Consultation documents given by the doctor/hospital
  • Prescriptions for drugs and the pharmacy bills
  • Investigation and diagnostic reports including laboratory reports, scans and X-rays
  • Medico Legal Certificate or FIR in case of an accident
  • Discharge summary provided by the hospital
  • A cancelled cheque leaf
  • A claim form with all particulars filled in

Points to remember while making a claim

Since the margin of error in making a health insurance claim is too thin, the policyholder should keep the following conditions in mind:

  • A minimum of 24 hours of hospitalisation is mandatory for claiming health insurance.
  • Application for claims should be made within 30 days from the date of discharge.
  • Certain claims need to be made only after the specified waiting period as per the policy agreement. This ranges from 30 days to 4 years, based on the type of ailment.
  • Pre-hospitalisation coverage can be availed only for treatment taken within 60 days prior to hospitalisation; post-hospitalisation coverage is available only for treatment taken within 90 days after hospitalisation (this time frame may vary slightly across insurance companies).
  • If the details in the claim application form are not filled in completely, the claim might be rejected.
  • Certain expenses which don’t come under insurance coverage should be paid by the policyholder.
  • Awareness about diseases and ailments the policy doesn’t cover, and about critical illness insurance, is a must.
  • If the policy has a co-pay feature, the policyholder has to pay a particular percentage of the hospital expenses from his own pocket. He can claim only the remaining amount.
  • Certain items such as bed pans, gauze bandage, cotton bandage, slings, nebuliser kits and cervical collars fall under the ‘Non-admissible expenses’ list, and cannot be included in the claim.
  • False and inflated claims should never be made for any reason, as they lead not only to rejection of the claim, but also to cancellation of the whole policy.

Getting a health insurance plan for your family is always a good decision to make. Now, all you need to do is to be cautious while making a claim, and make sure you bring down the healthcare costs as much as you can.

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