Claim

What is a claim in insurance?

A claim in insurance means asking your insurance company to pay for something your policy covers. If you are hospitalized due to an illness or accident, you can file a health insurance claim to get your hospital bills paid or reimbursed by the insurance company.

Types of insurance claims

1. Cashless claim

In a cashless claim, the insurer directly settles the hospital bills with the network hospital. You don’t have to make any payment at the time of discharge, except for non-medical expenses or exclusions.
Example:
If you are admitted to a network hospital that is part of your insurer’s network, you can avail of cashless treatment. The insurer pays the hospital directly after verifying the treatment details.

2. Reimbursement claim

In a reimbursement claim, the policyholder pays the hospital bills first and then submits the bills and related documents to the insurer for reimbursement.
Example:
If you choose a non-network hospital, you will pay the bills upfront and then file a reimbursement claim with the insurer to get your expenses refunded.

Documents for making a claim in insurance

To make a claim, you’ll need to submit essential documents like:

• Claim form (filled and signed)
• Doctor’s prescription and diagnosis report
• Hospital bills and discharge summary
• ID proof of the insured person
• Policy or health card copy

What is the claim form?

A claim form is a document that the policyholder fills out to officially request payment or reimbursement from the insurance company.

It includes important details such as:

• Policy number
• Type of claim (e.g., hospitalization, accident, etc.)
• Date and details of the incident
• Hospital or service provider information
• Amount being claimed

In simple words, the claim form tells the insurer what happened and how much money you’re requesting under your policy. It’s the first and most important step in the claim process.

What is claim status?

Claim status refers to the current progress or stage of your claim whether it is under review, approved, partially approved, or rejected.

How to check:
You can track your claim status online through your insurer’s website, mobile app, or TPA portal by entering your claim ID or policy number.

How to file an insurance claim?

Filing a claim can vary depending on whether it’s cashless or reimbursement, but the basic steps remain the same:

Step 1: Inform the insurer or TPA
Notify the insurer or Third-Party Administrator (TPA) immediately after hospitalization or the incident that requires a claim. Timely intimation helps avoid claim rejection.

Step 2: Submit the claim form and required documents
Provide the completed claim form along with necessary documents such as hospital bills, prescriptions, discharge summary, and reports.

Step 3: Claim verification
The insurer or TPA reviews the documents and verifies the claim details to ensure that the treatment or event falls within the policy coverage.

Step 4: Claim approval and settlement
Once approved, the insurer processes the payment.

• For cashless claims, the payment is made directly to the hospital.
  
  
• For reimbursement claims, the approved amount is transferred to the policyholder’s bank account.

Step 5: Track claim status
You can check your claim status anytime through the insurer’s website, mobile app, TPA portal, or your company’s HR benefits platform.

What is a no claim bonus (NCB) in health insurance?

A No Claim Bonus (NCB) is a reward offered by insurers to policyholders who do not file any claim during a policy year.

Benefits:

• Increases the sum insured for the next year at no extra cost.
• Alternatively, offers a discount on the renewal premium.

In group health insurance, some insurers offer a collective NCB benefit at the employer level if fewer employees raise claims during the policy year.

Common reasons for claim rejection

• Missing or incomplete documentation.
• Delay in informing the insurer or TPA about the hospitalization.
• Treatment or illness not covered under the policy (policy exclusions).
• Misrepresentation or incorrect information during claim submission.
• Claiming for expenses beyond policy limits or waiting period conditions.

Tips to ensure smooth claim settlement

• Understand your policy inclusions, exclusions, and claim limits before hospitalization.
• Always keep hospital bills, prescriptions, and reports well-organized.
• Inform the insurer or TPA as soon as hospitalization occurs.
• For group health insurance, contact your HR team or TPA for help with documentation and claim submission.
• Prefer network hospitals to avail cashless claims and reduce out-of-pocket expenses.

With Pazcare, companies can offer seamless claim support, cashless hospital assistance, and a digital platform to track employee health benefits.

Talk to a Pazcare expert today and simplify group health insurance for your team.