Health Insurance Claims

Unexpected growth in healthcare costs have compelled more and more Indians to opt for a suitable health insurance cover. However, many amongst us are not well versed with the nitty-gritties of claiming on the policy, in times required.

Health insurance is aimed to protect us financially against any unfortunate hospitalization and related expenses. Isn’t that the reason why we invested so much time and efforts in choosing the right plan and continued to pay the premiums year after year? However, regardless of this, there’s still lack of awareness about how to claim on your health insurance.

Pathway to Successful Health Insurance Claims

Your Health Insurance Policy Can Be Claimed in Two Ways:

Cashless Settlement

Every insurance company has network of hospitals that form a part of its PPN (Preferred Provider Network). When you wish to get treated in any of such hospitals, you are entitled for a cashless treatment where the insurance company/Third Party Administrator settles the cost of hospitalization and subsequent expenses directly with the hospital without involving you.

Reimbursement of Medical Expenses

In situations, where you are unable to get treated at a network hospital, you can opt for the hospitalization and the subsequent treatment in your choice of hospital, pay for the same through your pocket and then claim for reimbursement. In view of the huge costs involved that you need to bear at the time of discharge from the hospital, this may not appear to be a preferred choice for many.

A Health Insurance Cashless Claim Can Be Classified Under Two Categories

Claims against Planned Hospitalization

Cashless claims against planned hospitalization are applicable on medical treatment of diagnosed illnesses. Every insurance company has a list of network hospitals that are authorized to offer cashless benefits to the insured on hospitalization and medical facilities. You can avail cashless facilities by following the below process:

  • Fill up the claim form with details regarding the network hospital where the insured will be hospitalized.
  • Email the form or send it by fax to the insurance company or Third Party Administrator (TPA) for approval of the cashless claim at least 48 to 72 hours before the date of planned hospitalization.
  • After approval, the insurance company or TPA informs the hospital about the approved claim amount.
  • After the completion of treatment at the hospital, the insurance company or TPA directly pays the approved claim amount to the hospital.

Claims Against Emergency Hospitalization

Such claims are applicable for unforeseen emergencies rising due to an accident or a critical illness. In such cases, the insured or his/her family members should follow the below process:

  • Intimate the insurance company or TPA within 24 hours of hospitalization and send the filled up claims form by fax or email.
  • After reviewing the form, the insurance company or TPA takes a decision whether to approve or reject the cashless claims request.
  • The decision is communicated to the insured or his/her family member who had intimated them.

Types of Health Insurance Claims

Cashless Claims Form: Most modern insurance companies offer their policyholders cashless benefit at their respective network hospitals. To initiate the process of cashless claims for hospitalization and other medical facilities at a network hospital, a policyholder has to follow the claims procedure as mentioned in his/her policy document.

Reimbursement Claims Form: Reimbursement of claims applicable when the insurer does not offer you a cashless benefit or the insured had not been hospitalized at any of its network hospitals. In such cases, you have to submit relevant receipts and bills of hospitalization and medical facilities availed by you to your insurer to initiate the claims reimbursement process. Make sure that you read through your policy document for the claims process and the documents that you need to submit to initiate the claims reimbursement process with your insurer.

Personal Accident Claims Form: Personal accident insurance cover incidents like accidental death, permanent total disability and permanent partial disability. It covers hospital and ambulance charges for the insured up to a certain limit. The claim for helps in making accidental death or disability.

Global Personal Guard: Global personal guard policies financially protect the insured against death, permanent total disability and permanent partial disability, among other add-on covers. Claims for such expenses have to be made by submitting this form to the concerned insurance company.

Non-medical Expenses List: Every insurance company has a specific list of expenses that policyholders cannot claim. Some of these usually are baby food, cosmetics, Band Aid, health drinks, etc.

KYC Form: The applicant of a health insurance policy has to fill up a KYC (Know Your Customer) Form with required personal details like name, Proof of Identity (PoI), Proof of Address (PoA), contact number, etc. to enable the insurer to undertake a thorough background check and verify the accuracy of the information provided before offering him/her a health insurance policy.

How to Claim Health Insurance?

Every insurer has laid down few procedures to enable hassle free claim process. Hence, it’s important to be aware of these processes to avoid any eleventh hour surprise. Please refer the following for raising successful claims.

For Cashless Settlement

  • Intimate the insurance company at least 1-2 days in advance in case of planned hospitalization. An intimation should be sent to the insurance company within 24 hours, if it’s an emergency hospitalization.

  • Most network hospitals have a dedicated TPA (Third Party Administrator) helpdesk that assist the insurers with all the necessary documentation and formalities. Hence, it’s significant to contact the TPA desk to fill the claim form and submit the necessary documents like health card, doctor’s report, etc.

  • Once these documents are received by the insurance company/TPA, they are scrutinized to check against the policy coverage and terms.

  • If within the scope of coverage, an approval is sent to the hospital for a specific amount. Should the cost of treatment exceed the approved amount, the hospital can request for the re-approval.

  • If the request for cashless treatment is denied, one can pay towards the hospitalization and treatment from his own pocket and then raise the request for reimbursement.

For Reimbursement of Claims

  • As in cashless settlement, an intimation to the insurance company is mandatory even if you wish to go for reimbursement way.

  • After the hospitalization post necessary treatment, you have to submit the necessary documents to the insurance company/TPA to kick-start the process. Following documents must be submitted to enable smooth processing:

    • Duly completed claim form
    • Discharge summary signed by the treating doctor/hospital
    • All medical bills along with the related prescriptions
    • As per the pre-post hospitalization cover clause in your policy document, you can also submit the expenses/OPD costs related to the hospitalization sought
    • Copy of cancelled cheque
    • Any other necessary documents on the request of the insurance company
  • Post scrutiny of your claim request and the documentation you submit, your claim will be accepted/denied basis the policy terms and conditions.

  • If your claim is accepted, the final amount is disbursed along with the Claim Settlement Letter specifying the break-up of the amount.

  • If the claim is denied on valid grounds, Claim Rejection Letter will be shared with the insured stating the reasons for the same.

Must Read: Things to do when your Health Insurance Claim gets Rejected

Two Types of Health Insurance Cashless Claim Process

The claims process in case of treatment at a network hospital will differ depending on the kind of treatment – Planned or Unplanned. Unplanned treatment at a network hospital usually occurs in the event of an emergency.

Planned Hospitalization

For the purpose of availing cashless treatment, the most essential part is to make the insurance company aware of the nature of illness and get approval for its treatment from the TPA. Prior to hospitalization, one needs to fill up the necessary documents for admission, like pre-authorization forms. Then, these need to be submitted at the insurance desk (every network hospital will have a dedicated insurance desk). The form will get approved or rejected on the basis of the terms and conditions listed in the policy. If the form is approved, then the TPA will send the sanction letter to the hospital and the treatment can be started thereon.

Emergency Hospitalization

In the event of an emergency hospitalization, the policyholder can show his or her Health ID card at the network hospital to avail cashless facility. The preauthorization request can be sent to the TPA after admission. It is therefore important that one carries their Health ID card at all times as emergencies are unpredictable. In a situation where the card cannot be produced at the network hospital, then at least the policy number and a photo ID need to be produced at the hospital for pre-authorization. The health ID card can later be shown at the time of hospitalization. An ‘Emergency certificate’ also has to be submitted with the pre-authorization form to the TPA, stating the emergency nature of admission.

Few Pointers of Health Insurance Claims

  • To claim on your health insurance, a minimum of 24 hour hospitalization is mandatory.

  • When you receive the policy documents, please refer the policy wordings for the terms and conditions related to your plan including the process to follow in case of claims.

  • Every insurance company has set certain time frames to follow in case of various processes. Ensure to follow them to avoid any surprises.

  • Be aware what’s covered and what’s not in your health insurance plan. More than what’s covered, it’s important to pay close attention to what’s not.

  • Share a copy of your policy documents, health card and contact details of the insurance company/TPA with your family, friends along with the process to follow in case you are in no position to follow the procedure yourself.

  • Keep an eye on the waiting periods for claiming on your insurance policy.

  • Last but not the least, ensure you maintain a proper file with all the prescriptions, medical bills, etc. for easy availability.

Why Coverfox Should Be Your Ideal Choice?

Coverfox, being an IRDAI certified broker, is well equipped to handle all your queries and concerns regarding claiming on your health insurance policy. We can be your ultimate choice with the below services on offer:

Claim Intimation

We can intimate the claim to the insurance company on your behalf saving a lot of your valuable time and efforts.

Documents Pick-Up

We can arrange to pick up all your claim related documents from your home/office as per your convenience.

Documents Scrutiny

We have dedicated and qualified Claims Team who thoroughly scrutinize your documents for correctness or any missing information before submitting them to the insurance company/TPA. This saves a lot of your time in back and forth coordination with the insurance company/TPA. The team can also provide a rough estimation of the claim amount that you can expect to get compensated for.

Follow-Up and Status Update

We understand your anxiety when it comes to claiming on your health insurance. Therefore, we keep you posted with all the updates related to your claim assuring complete peace of mind. Similarly, we follow up with the insurance company/TPA for the timely disbursement of the claim amount.

Dispute Resolution

At last, we will be there for you at the most crucial time – when you really need us. In case you are not satisfied with the outcome of your request, we will raise the same with the insurance company and if required, also help you dealing with it through grievance cell.

FAQs on Health Insurance Claims

I have just bought a health insurance plan. Am I entitled for the cashless treatment?

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.

What if the insurance company deny my request for cashless treatment?

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.

What are the charges/expenses that are not covered in the health insurance?

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.

Is there any waiting period to claim on my health insurance?

Typically, every health insurance policy is bundled with three types of waiting periods.

  • The initial waiting period: This specifies to an initial 30 days of waiting period where you cannot raise a claim on your health policy except in case of an accident.

  • Ailment specific waiting period: There are certain ailments that are covered by the health policy only after a certain waiting period such as two years. This list varies as per insurance company and is mentioned in the policy wordings.

  • Pre-existing Disease waiting period: Most insurance companies cover the pre-existing diseases after a waiting period of 3-4 years. Hence, if you have specified any illness as pre-existing during the time of policy purchase, the same will be covered only after the waiting period mentioned in your policy.

What is claim loading in health insurance?

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.

Can I claim from two health insurance policies?

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.

How long does it take for health insurance companies to pay a claim?

Most health insurance companies take around 30 to 45 days to pay claims.

Can I file my own health insurance claim?

Yes, you can file your own health insurance claim.

Can I claim health insurance online?

Yes, you can make a claim on your health insurance plan online if your insurer or Third Party Administrator (TPA) offers the facility.

When can we claim health insurance?

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.

How long do insurance claims take to settle?

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.

Is claiming two health insurance policies possible?

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.

How many types of expenses can be claimed in a health insurance 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.