Health Insurance Claims

Medical claims are generally categorised into two types: cashless claims and reimbursement claims. The type of health insurance claim you can avail depends on factors such as the hospital you choose, your insurer's network, and the circumstances of the treatment.

1. Cashless Claims

A cashless medical insurance claim enables policyholders to receive treatment at a network hospital without paying the entire hospital bill out of pocket. The insurer directly settles the eligible medical expenses with the hospital, making it a convenient option during planned or emergency hospitalisations.

When can you use it?

• When receiving treatment at a network hospital.

• For planned hospitalisations with prior approval from the insurer.

• For emergency hospitalisations, subject to the insurer's notification requirements.

2. Reimbursement Claims

A reimbursement medical insurance claim allows policyholders to recover eligible medical expenses incurred during treatment. This option is commonly used when treatment is received at a non-network hospital or when a cashless claim facility is not available.

When can you use it?

• When receiving treatment at a non-network hospital.

• When a cashless claim cannot be processed or approved.

• When the policyholder pays the hospital expenses and seeks reimbursement later.

The health insurance claim procedure involves notifying the insurer about the hospitalisation, providing the necessary documents, and completing the required formalities to receive coverage for eligible medical expenses. While the exact process may vary among insurers, most claims follow a similar sequence of steps, depending on the claim type:

Cashless Health Insurance Claim Process

A cashless claim allows eligible medical expenses to be settled directly between the insurer and a network hospital, reducing the financial burden on the policyholder during treatment.

Step 1: Choose a Network Hospital

Select a hospital that is part of your insurer's network hospital list.

Step 2: Submit a Pre-Authorisation Request

Provide your health insurance details and complete the pre-authorisation form at the hospital.

Step 3: Insurer or TPA Approval

The insurer or TPA evaluates the request and approves the cashless claim based on policy coverage and eligibility.

Step 4: Treatment and Hospitalisation

Receive the required medical treatment at the network hospital.

Step 5: Direct Claim Settlement

After discharge, the insurer settles the approved medical expenses directly with the hospital. The policyholder is responsible only for non-covered expenses, deductibles, or exclusions, if applicable.

Reimbursement Health Insurance Claim Process

A reimbursement claim is used when treatment is received at a non-network hospital or when a cashless facility is unavailable.

Step 1: Receive Medical Treatment

Undergo treatment at the hospital and complete the required medical procedures.

Step 2: Pay Hospital Bills Upfront

Settle all hospital and treatment-related expenses directly with the healthcare provider.

Step 3: Collect Required Documents

Obtain all original bills, receipts, discharge summaries, prescriptions, and supporting medical records.

Step 4: Submit the Claim to the Insurer

Complete the claim form and submit it along with the required documents within the insurer's prescribed timeframe.

Step 5: Claim Review and Reimbursement

The insurer verifies the documents and assesses the claim. Upon approval, the eligible amount is reimbursed to the policyholder's registered bank account.

Documents Required for Health Insurance Claims

The documents required may vary depending on the insurer and the nature of the claim. However, the following documents are commonly requested:

• Health insurance policy details or policy number

• Duly filled and signed claim form

• Hospital discharge summary

• Doctor's prescriptions and consultation records

• Medical reports and treatment records

• Original hospital bills and payment receipts

• Pharmacy bills and medicine invoices

• Diagnostic test reports and investigation records

• Identity proof, if required by the insurer

• Cancelled cheque or bank account details for reimbursement claims

• Any additional documents requested by the insurer during claim assessment

Note: Insurers may request additional documents depending on the type of treatment, claim amount, and policy terms.

Pro Tip: Nowadays, most insurers have a mobile application to navigate and initiate the claim process for their policyholders. Always check your insurer-specific claim process for ease during the time of need.

Once a health insurance claim has been registered, policyholders can track its progress through multiple channels to stay informed about approvals, document requirements, and settlement updates.

• Contact Coverfox Support

If you purchased your policy through Coverfox, you can check your claim status by emailing help@coverfox.com or contacting the Coverfox customer support team. The support team can assist with claim updates and help coordinate with the insurer when required.

• Contact the Insurer's Customer Support

Most health insurers offer dedicated claim support through their customer care helpline, email, or branch offices. By providing your policy details and claim reference number, you can obtain the latest status of your claim.

• Use the Insurer's Claims Portal or Mobile App

Many insurers allow policyholders to track claims online through their official website or mobile application. Simply log in to your account and navigate to the claims section to view real-time updates.

• Track Using the Claim Reference Number

When a claim is registered, the insurer or TPA typically provides a claim reference number (also known as a claim ID or claim registration number). This unique number can be used to track the claim status through customer support channels, online portals, or mobile apps.

If you have more than one health insurance policy, you can claim medical expenses from multiple insurers when the hospitalisation cost exceeds the coverage available under a single policy. This is known as a multiple health insurance claim and helps policyholders maximise their available coverage while reducing out-of-pocket expenses.

How Does It Work?

When you hold multiple health insurance policies, you can choose any one insurer as the primary insurer for the claim. If the hospital bill exceeds the amount settled by the primary insurer, the remaining eligible expenses can be claimed from the second insurer, subject to the terms and conditions of that policy.

For example, if your hospital bill is ₹8 lakh and your first insurer settles ₹5 lakh, you can submit the balance ₹3 lakh claim to the second insurer, provided you have sufficient coverage available.

Steps to Claim Health Insurance from Multiple Insurers

Step 1: Inform All Insurers

Notify all the insurers with whom you hold active health insurance policies about the hospitalisation and your intention to claim under multiple policies.

Step 2: Choose the Primary Insurer

Select the insurer from whom you want to make the first claim. This insurer will process the claim according to the policy terms and settle the eligible amount.

Step 3: Submit the Claim Documents

Provide the required claim documents to the primary insurer, including hospital bills, discharge summary, medical reports, and claim forms.

Step 4: Obtain Settlement Documents

After the claim is settled, collect the settlement letter, claim payment details, and certified copies of the claim documents from the primary insurer.

Step 5: Submit the Balance Claim to the Second Insurer

Submit the remaining unpaid expenses along with the settlement documents received from the primary insurer to the second insurer.

Step 6: Claim Assessment by the Second Insurer

The second insurer reviews the claim, verifies the remaining eligible expenses, and assesses the claim according to its policy terms and coverage limits.

Step 7: Receive the Remaining Claim Amount

If approved, the second insurer reimburses the remaining eligible medical expenses up to the available sum insured under the policy.

Important Note: The total claim amount received from all insurers cannot exceed the actual medical expenses incurred. Additionally, all claims remain subject to policy exclusions, waiting periods, deductibles, and other applicable terms and conditions.

Being aware of common claim rejection triggers can help you avoid mistakes and improve the likelihood of a successful claim settlement.

A little preparation can go a long way in ensuring your health insurance claim is processed smoothly and without unnecessary delays.

• Keep your policy number and health insurance card readily available.

• Check whether the hospital is part of your insurer's network.

• Understand whether you need a cashless or reimbursement claim.

• Inform the insurer or TPA within the required timeline.

• Retain all medical records, prescriptions, and diagnostic reports.

• Collect detailed hospital bills and payment receipts.

• Verify that all documents contain accurate patient details.

• Keep copies of every document submitted to the insurer.

• Note down the claim reference number for future follow-ups.

• Regularly track the claim status until it is settled.