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Health Insurance Claim Process | Medical Insurance Claim Settlement

Health insurance claim

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Health insurance claim is a request to the insurer of the beneficiary to finally give the cover/ benefits that has been promised to you by the provider. An insured can opt for direct claim or can either the reimbursement as per the requirement that you have.

You can request the provider for a cashless claim at the network hospitals.

Types of health insurance claim

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Providing health care at the time of much need is the most important utility of an insurance plan. There are two ways in which you can get a health insurance claim.

Cashless claim: you can get the hospitalisation at any network hospital and not pay a single penny. You can just submit to your insurer all the bills, payment receipts etc and also you should know that you should have to be hospitalised at the any network hospital for a few days to avail this benefit.

Reimbursement: the insured pay the amount of hospitalisation by himself and then requests the claim from the insurance provider, after having submitted the original bills, receipts etc.

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Important Conditions to avail the claim

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  • The authorisation can be cancelled if the details filled are false or incomplete
  • claim should filed within the 30 days of recharge
  • The non payable items shall be paid for by the insured himself
  • To claim the entire post hospitalisation expenses, you should file for the claim within 30 days of the discharge date.

A health insurance cashless claim can be of two types:

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Planned hospitalisation: Planned hospitalisation comes in picture when the policyholder is aware of the hospitalisation beforehand. The steps to claim cashless treatment in this case are:

  • Contact the toll-free helpline number of the health insurance policy provider beforehand.
  • Fax the pre-authorisation form, which must be duly filled by the hospital, to the fax number of the health insurance provider.
  • Contact the toll-free helpline number of the health insurance policy provider beforehand.

Emergency Hospitalisation: Generally, an emergency hospitalisation is needed when the insured meets with an accident or is suffering from an illness that needs immediate hospitalisation.

  • In such a situation, the family of the insured is asked to contact the health insurance provider on their toll-free number after admitting the patient to the hospital.
  • Now, the pre-authorised form (fully-filled) has to be faxed on the numbers of the health insurance provider within 24 hours of hospitalisation.

Documents required to file a claim settlement

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  • Health insurance ID card
  • All the consultation papers provided by the doctor
  • Completely filled claim form
  • All reports, CT scan, MRI etc
  • FIR in case of accidental claim
  • Invoices of the pharmacy with proper prescriptions
  • Discharge summary
  • All other documents required

It is all that you should know about a health insurance claim. Also note that there are different claim processes for both types of claims: cashless claim and reimbursement claim.

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