Health Insurance Claim Process - How Does It Work?

What is a health insurance claim?

A health insurance claim is a request that a health insurance policyholder submits to a health insurance company to get the services mentioned in their health plan/policy during hospitalization or medical treatments. By sending this request, the health insurer is notified to initiate the claim process. 

Types of claim in health insurance

There are two types of claim initiation in health insurance. They are cashless claims and reimbursement claims.

Cashless claim

As the name suggests, it frees us from handling money during medical emergencies. In a cashless claim, the insurer settles the medical bills directly to the hospital itself. This is applicable only if the policyholder is admitted to a network hospital. A network hospital is a hospital that has an agreement with the insurer to provide cashless treatment to the insured.

The policyholder or the insured can provide the details of the insurance policy taken along with the ID card provided by the insurer in the network hospital. After this the hospital will verify the details and submit the pre-authorization form to the insurer. Once the patient is discharged, the bills are sent to the insurer. The insurer verifies it and settles the bill to the hospital.

Hence, it makes you worry-free about settling the bills to the hospital.

Cashless claim during planned hospitalization

In the case of surgery, hospitalization is planned. Hence, the policyholder can avail cashless claims for planned treatments and hospitalization.

• For availing of cashless claims, inform the insurance company beforehand. This is usually 4 days before the hospitalization.

Cashless claim for emergency hospitalization

For availing of a cashless claim for emergency hospitalization, you will have to inform the insurance company about the hospitalization to the nearest network hospital. Show valid proof that you hold the policy, for instance, a health insurance  ID card provided by the insurer, and fill the necessary forms, you are good to go.

Reimbursement claim

In a reimbursement claim, once the insured is admitted to a hospital, the bills are paid from your pockets. Later, the insurance company will reimburse the claim amount to you once you provide the necessary documentation. 

This is mostly the case when the policyholder goes to a hospital that is not in the network hospital list of the insurer. However, the claims are settled by evaluating the credibility of the documents you provide. 

This is why it is important to choose an insurer with an extensive hospital network and a high claim settlement ratio. A claim settlement ratio suggests the percentage of claims settled by the insurance company to the policyholders in a financial year. The higher the ratio, the higher is the chance of your claims being settled.

Health insurance claim process

The health insurance claim process varies for a cashless claim and a reimbursement claim. Let us see how it is done.

Cashless health insurance claim procedure

The cashless health insurance claim procedure generally consists of the following steps

• Firstly contact your insurer or you can contact the insurance help desk in the hospital.
• Then, show valid proof like your health ID card - proof to show you hold a valid health insurance policy, unique identification card like a copy of Aadhar or driving license to the person in charge at the hospital.
• After the verification process is complete, the hospital will submit the pre-authorization form provided by the insurer.
• A few health insurers will assign field doctors to make the claim process easier for the insured. 
• After successful verification of the documents submitted, the claims will be initiated and settled according to the terms and conditions of your health insurance policy. 

In case of planned hospitalization

• Inform the insurer at least 4 days before the treatment/hospitalization date. You can contact the toll-free number of the insurance provider.
• After the admission to the hospital, the hospital will fill the pre-authorization form and fax or email it to the insurer after the policyholder submits the valid proof.
• Once the process is complete, the insurance company will inform about the coverage provided to the policyholder and the network hospital.
• After all of this, the insurance company will settle the bills to the network hospital.

Reimbursement claim procedure

The reimbursement claims can be initiated in a hospital of your choice. The general procedure includes

• The insured or the policyholder has to pay all the medical bills and other costs involved in the hospitalization. Make sure you keep all the bills safely for the claim.
• Submit the original bills to the insurer along with a duly filled claim form. The claim forms are mostly available on the website of the insurer or their offices.
• After this, the claim request is verified and processed according to the terms and conditions of the policy.
• Once the claim is verified and the bills are credible the insurer settles the payment to the account of the policyholder.

Documents required for health insurance claim

• Duly filled claim form. Available on the website or the offices of the insurer.
• A health insurance ID card provided by the insurer.
• A valid unique identity card like Aadhar, Voter Id, etc.
• All the original medical bills and pharmacy bills.
• Doctor consultation and prescription papers.
• Investigation report
• Discharge summary from the hospital.
• A medical certificate signed by the doctor in charge.
• For accidents, FIR or MLC (Medico Legal Certificate) copy
• Other relevant documents.

Claim authorization in health insurance

• Immediately after the policyholder or the attendant of the insured intimates the claim to the insurance provider, the insurer verifies the policy and the coverage of that policy.
• After the verification process by a field doctor, the pre-authorization form is submitted and the cashless claims are approved.
• This authorization process can even get canceled if the details mentioned are incorrect.
• The claims must be filed within 30 days of discharge from the hospital and intimated at least 4 days before the planned hospitalization.
• The insured will have to pay for all other expenses which are not covered under their health insurance policy.

Mostly Third Party Administrators or TPA in health insurance verify the documents and claims. Any claims that are invalid or the details provided are incorrect are rejected.

Also read: Domiciliary Hospitalization – Health Insurance and Claim