Here’s How To Make Health Insurance Claims

For many people, health insurance is the safety net that prevents a medical emergency from turning into a financial burden. Yet, policyholders often find themselves confused while filing claims.

Typically, insurers settle claims in two ways. Cashless service is available at network hospitals, where the insurer directly pays the hospital. Reimbursement happens when treatment is taken at a non-network hospital, or if a cashless request is denied.

With rising healthcare costs, a claim denial or delay can cause distress.

Here’s a guide to filing claims under both modes.

Cashless Claim

1. Choose a network hospital as you can claim only at hospitals listed under the insurer’s or third-party administrator’s (TPA) network.

2. At the time of admission, present your policy details at the TPA desk for identification.

3. The hospital will provide a pre-authorisation form. Fill details of the treatment, diagnosis, and your policy.

4. The hospital will forward the form and medical details to the insurer or TPA for review.

5. Once approved, the insurer will pay the hospital. You will have to pay costs not covered under your policy, such as consumables.

Reimbursement Claim

1. Inform your insurer or TPA 48 hours before admission or 24 hours prior In case of an emergency.

2. As reimbursement applies to non-network hospitals, you must pay the hospital bills upfront at the time of discharge.

3. Collect all documents, including claim form, discharge summary, doctor’s prescription, reports, original bills and receipts, pharmacy invoices, and payment proofs. In case of an accident, additional documents like FIR or medico-legal certificate may also be required. Submit bank details if asked for by the insurance company.

4. File the reimbursement claim within 15-30 days of discharge, either online, on mail or physically at the insurer’s office.

5. If approved, the insurer will transfer the claim amount to your bank. They can reimburse or reject the claim within 30 days of receiving all the claim documents.

Documents Required

For Cashless Claims

• Health card or copy of policy document

• Pre-authorisation form from hospital

• Doctor’s prescription and consultation papers

• Diagnostic test reports

• Identity proof of insured

• Hospital admission and discharge summary (shared directly by hospital with insurer)

For Reimbursement

• Filled and signed health insurance claim form

• Copy of health card or policy document

• Original hospital discharge summary, medical certificate and reports; hospital, pharmacy and diagnostic bills; payment receipts.)

• FIR/Medico-Legal Certificate for accident

• Copy of KYC documents of policyholder/claimant

• Bank details with NEFT information or a cancelled cheque