You buy a health insurance plan and pay a premium in return for which the insurance provider promises to reimburse your medical bills when there is a requirement. The payment of the medical bills by the health insurance company is known as a health insurance claim payout and is one of the most important components of this type of coverage.
Health insurance claims are available in different categories and there are specific ways in which you can go about the process. Read on to learn more about the claims and how you can make them work in your favour.
As stated, there are multiple ways in which you can receive a health insurance claim. The most popular ways include:
It is one of the simplest and most convenient ways of getting a medical insurance claim. Here, your hospital stay becomes cashless, as the insurance provider directly settles the bill amount with the hospital, on your behalf.
All you have to do is inform the insurer about your hospitalisation, preferably in advance for planned hospitalisation and fill out a pre-authorisation form. Even in case of emergency hospitalisation, the pre-authorisation form needs to be filled within 24 hours of hospitalisation.
Then, you have to submit your health card to the hospital’s insurance desk along with the insured’s identity documents. The insurer will get in touch with the hospital, carry out the verification process and settle the bill, provided everything is in place. A cashless claim can only happen at a network hospital, though. However, with the new rule of “cashless everywhere”, cashless claims can happen even in non-network hospitals.
If you opt to get treated at a non-network hospital, or if you seek treatment during an emergency and make the payment yourself, you can still get the amount from the insurance provider. This is called a reimbursement.
After discharge, you have to submit all the documents to the insurance provider, such as the original hospital bills, doctors’ certificates, etc. to the insurer and get them to reimburse the amount to you. You can claim online health insurance by submitting the papers on the insurer’s portal or do it offline by visiting the office of the insurance company. The insurer will verify the documents and then pay the reimbursement claim.
Cashless claims and reimbursement claims are two methods used in insurance to process and settle claims. Both methods offer several benefits to policyholders.
Cashless claims provide a convenient way to avail of medical services without paying upfront. Policyholders can simply show their health insurance card and receive treatment at network hospitals without the hassle of arranging cash.
Reimbursement claims, on the other hand, allow policyholders to get treated at any hospital and then claim for reimbursement later.
Cashless claims ensure that policyholders get immediate access to medical treatment without delays. This can be crucial in emergencies when time is of the essence.
Reimbursement claims may require policyholders to pay upfront but provide the flexibility to choose any hospital or healthcare provider.
Cashless claims help policyholders manage their finances better by avoiding unexpected out-of-pocket expenses. By utilizing the network hospitals, policyholders are charged directly to the insurance company, reducing the financial burden.
In the case of reimbursement claims, policyholders can still claim the expenses incurred but will need to submit relevant documents for approval.
Cashless claims tend to have simpler documentation requirements as the hospital directly coordinates with the insurance company for billing and settlement.
Reimbursement claims require policyholders to maintain and submit all the necessary documents, including medical bills, prescriptions, and reports.
Cashless claims ensure transparency in billing and settlement as the insurance company and the hospital directly communicate and negotiate rates.
Reimbursement claims allow policyholders to review all the bills and expenses incurred, ensuring transparency and accuracy in settling claims.
Insurance providers usually have tie-ups with a wide network of hospitals for cashless claims. This means that policyholders have access to quality healthcare facilities without worrying about upfront payments.
Reimbursement claims, on the other hand, allow policyholders to choose any hospital or healthcare provider, providing more flexibility in terms of treatment options.
In summary, both cashless claims and reimbursement claims offer different benefits to policyholders. Cashless claims provide convenience, quick access to healthcare, and cost-effectiveness, while reimbursement claims offer flexibility, transparency, and a broader choice of hospitals. Policyholders should understand their insurance coverage and choose the claim method that best suits their needs and preferences.
Modern-day health insurance has become very systematic and streamlined. If you have the documents in place and you make a claim on time, the insurance provider will honour your request, provided you honour the terms and conditions. One of the most important requirements for getting a health insurance claim smoothly is submitting documents. Here are some of the papers that you must submit along with your claim application:
These are some of the most important papers needed when submitting a health insurance claim. Be thorough when you submit an application and ensure there are no errors, as that will help you to get the claim quickly and smoothly.
As stated, a health insurance claim can be made in two ways, either cashless or through reimbursement. You need to be aware of what is reimbursement claim, what is cashless claim and which one you are eligible for. Most people opt for the cashless method as it is convenient and fast. Here are the steps to follow if you wish to get a cashless health insurance claim:
If you opt for the reimbursement claim settlement option, you will have to settle the hospital bill on your own at the time of the discharge. Then, you will have to submit all the documents to the insurance provider, who after verifying, will directly send the claim amount to your bank account.
In India, making a health insurance claim from multiple insurance companies follows a similar process with a few additional steps:
It is important to carefully review and understand the policies of all the insurance companies involved to ensure a smooth claims process. Additionally, it is advisable to maintain proper communication and documentation throughout the process to minimize any potential difficulties.
To check the status of a health insurance claim, you can follow these general steps:
Remember that the specific process may vary depending on your insurance provider and location. Always refer to the instructions and guidelines provided by your insurance company.
You buy a health insurance plan and expect it to pay you the claim amount when needed. This is why you should choose a bankable insurance company that steadily pays out the claims diligently. Doing so will ensure you get the financial assistance when you need it the most. To understand this, you must understand what a claim settlement ratio is, and what is understood by the incurred claim ratio, both of which play an important role.
Here is a list of the best Health Insurance providers in India, along with their claim settlement ratio and incurred claims ratio.
| Insurance Company | Claim Settlement Ratio 2023-24 |
|---|---|
| Acko General Insurance Co. Ltd. | |
| Bajaj Allianz General Insurance Co. Ltd. | |
| Cholamandalam MS General Insurance Co. Ltd. | |
| Future Generali India Insurance Co. Ltd. | |
| Go Digit General Insurance Ltd. | |
| HDFC ERGO General Insurance Co. Ltd. | |
| ICICI Lombard General Insurance Co. Ltd. | |
| IFFCO Tokio General Insurance Co. Ltd. | |
| Kotak Mahindra General Insurance Co. Ltd. | |
| Liberty General Insurance Co. Ltd. | |
| Magma HDI General Insurance Co. Ltd. | |
| Navi General Insurance Co. Ltd. | |
| Raheja qBE General Insurance Co. Ltd. | |
| Reliance General Insurance Co. Ltd. | |
| Royal Sundaram General Insurance Co. Ltd. | |
| SBI General Insurance Co. Ltd. | |
| Shriram General Insurance Co. Ltd. | |
| TATA AIG General Insurance Co. Ltd. | |
| Universal Sompo General Insurance Co. Ltd. | |
| National Insurance Co. Ltd. | |
| The New India Assurance Co. Ltd. | |
| Star Health and Allied Insurance Co. Ltd. | |
| The Oriental Insurance Co. Ltd. | |
| United India Insurance Co. Ltd. | |
| Aditya Birla Health Insurance Co. Ltd. | |
| Care Health Insurance Ltd. | |
| ManipalCigna Health Insurance Co. Ltd. | |
| Niva Bupa Health Insurance Co. Ltd. |
The COVID-19 pandemic hit in 2020 which led to thousands of people being hospitalised every day. This was one of the main reasons that the overall health insurance claim rate rise by over 257% by 2021.
This article explains the entire scenario in detail as to why health claims increased.
Here are some common reasons why a health insurance claim can get rejected.
Many people make fraudulent claims and this is the leading reason for health insurance claim rejections. For example, a person may submit fake hospital documents to prove he had surgery, while he wasn't even admitted to the hospital. At times, the bills are fabricated and the claim amount is increased, even when the original treatment cost is much lower. The insurance provider carries out strict checks and rejects all fraudulent claims. If it is found that someone is trying to buy health insurance claims by unfair means, it will be rejected.
You can only make a claim on a valid health insurance policy. If the policy has expired or lapsed, no claim can be made. This is why it becomes extremely important for you to renew your health insurance plan on time and enjoy uninterrupted coverage.
Every health insurance plan comes with a set of exclusions, such as dental treatments, cosmetic surgeries, etc. If you submit a claim for a procedure that is not included in the coverage, your claim will be rejected right away. Hence, be aware of what is covered in your policy and make the claim accordingly to avoid any disappointment.
Most of the health insurance plans in India have a waiting period clause attached to them. Certain treatments and procedures are only covered after you complete a designated time in the policy. For example, maternity covers are available after you complete 3 years in a plan. If you make a maternity claim in the first year of the coverage, it will be turned down by the health insurance company. There are many terms and clauses associated with a health insurance plan. You should read the clauses very carefully when buying a policy and be aware of the inclusions and exclusions, as that will help you lower the chance of a health insurance claim rejection.
In the majority of cases, you will require hospitalisation to get a health insurance claim. A minimum hospital stay of 24 hours is required. However, you can get a claim without spending a night in the hospital if you opt for a daycare procedure or get a diagnostic test done. You can also get other claims under overheads such as preventive health checkups, domiciliary care, etc without staying at the hospital.
As per the rules of the IRDA, no Indian insurance company has the right to reject a valid health insurance claim if the premiums have been paid and the cover is active. Your claim can be rejected due to improper documentation or due to exclusion, but it has to be honoured if the claim is within the permissible terms and conditions.
Every insurance company has a strong digital presence. They have advanced and modern websites where all the clauses related to the health insurance policy are stated. The list of inclusions and exclusions is also clearly stated on the website. Additionally, a complete list of exclusions is provided on your health insurance policy document.
As stated above, there is a waiting period associated with most health insurance plans in India. You cannot claim till the waiting period is exhausted.
Claim loading refers to the change of the health insurance premium that happens at the time of renewal, after a policy year that saw a claim. The premium is changed, based on the number and volume of claims made.
Every health insurance plan entitles for the cashless treatment provided you seek it in a hospital that is within the network of the insurance company. As mentioned earlier, a minimum of 24 hours of hospitalization is mandatory to claim on your health insurance.
As per the IRDAI guidelines, no insurer can deny your valid claim. Hence, if your request for the cashless treatment is denied due to valid reasons, you can still pay towards the treatment and all related expenses through your own pocket and then raise the request for reimbursement. If your claim request is within the scope of coverage as per the policy terms and conditions, it cannot be rejected.
There are certain expenses that are not covered in any health insurance plan such as administrative charge, services charge, expenses related to laundry, extra bed, toiletries, diapers, syringes, telephone charges, etc. For detailed information on whats not covered by your insurance company, please refer the policy wordings.
Typically, every health insurance policy is bundled with three types of waiting periods.
Claim loading is the amount charged by the health insurance company on your renewal premium when you make claims in your policy. Most health insurance companies contain loading in their policies. There are different ways in which loading is calculated by the enterprises.
Yes, you can claim against more than one insurance policy if the expenses are more than the sum insured of a single health insurance policy.
Most health insurance companies take around 30 to 45 days to pay claims.
Yes, you can file your own health insurance claim.
Yes, you can make a claim on your health insurance plan online if your insurer or Third Party Administrator (TPA) offers the facility.
Most health insurance policies come with an initial waiting period of 30 to 90 days - which means that any disease contracted during this period will not be paid for, except for accident cases.
The time taken to settle reimbursement claims will differ from one insurance company to another. It can take anywhere from a couple of days to a month or so for the company to settle claims. In case of cashless claim requests, most insurers have their own turnaround time.
If a life insured is covered under two health insurance policies, the individual can choose under which policy he or she would like to make the claim. If the amount claimed is greater than the sum insured under the policy on which the first claim was made, the individual can claim the remaining amount from the second policy.
Health insurance policies generally cover all kinds of medical treatment expenses with the exception of treatment for pre-existing health issues, eye & dental care, intentional self-injury and life-style induced diseases.
