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Health Insurance Claim Process

Making a claim against a health insurance plan is not difficult if you know the steps to be followed. Additionally, fulfilling the simple requirements of the claim process helps towards faster and seamless health insurance claims settlement.

Let's understand the claim process of health insurance in India.

Firstly, there are two types of claims processes – cashless and reimbursement.

Here is the claim process for each one explained in detail:

Cashless claim process

Cashless claims are eligible for treatments at a Preferred Provider Network (PPN). PPNs are a network of hospitals or care providers who have entered agreements wherein the insurance company pays the hospital for treatment costs incurred by the company's policy holders. The amount payable is the sum assured and as per the terms and conditions of the health policy purchased.

The following steps are necessary for cashless claims:

Inform the insurance company – for planned procedures and hospitalization, atleast 3-4 days in advance. If possible, schedule the surgery only after confirmation by the insurance company. In case of emergency, inform the insurer immediately.

Produce the health card - provided by the insurance company to all members covered under a plan. Show this along with an identity proof at the time of admission.

Share all health-related documents to insurance providers - which include scan reports, prescriptions, etc. Ensure the hospital does the same.

Fill and submit the cashless claim form – with the insurance company to process the claim. In case of emergencies, the hospitals are tasked with this process. For planned procedures, the policyholder is expected to complete the process.

Authorization letter is sent - by the insurance company to the hospital in case of an emergency. For a planned treatment, the policyholder is expected to complete the task.

Retain all the original medical bills - doctor's reports, investigative reports, etc. These documents are to be submitted with the claim form

Hospitals bills to be settled – directly by the insurance company

Claim Process Planned Treatment/Procedures Emergency Hospital Care
Inform the Insurance Company 3-4 days in advance Immediately
Produce at health card/identity proof At the time of hospitalization At the time of hospitalization
Share health-related documents Before getting approvals. Post-surgery to be shared by the medical team All documents to be shared by the medical team
Cashless Claim Free Firm Policyholder to fill the form before treatment Hospital/medical team's responsibility
Authorization/Approval Policyholder to get approvals before treatment Hospital/medical team's responsibility
Bill payments Paid by the insurance company directly to the network hospital Paid by the insurance company directly to the network hospital

Reimbursement claim process

Reimbursement claims are for treatments at a non-network hospital. The policyholder makes payment for the treatment costs incurred from their own pocket and the money is reimbursed in their account after verification.

The following steps are necessary for reimbursement claim procedure:

  • Get admitted to a hospital and pay the relevant medical expenses incurred.
  • Obtain all the original medical bills, doctor's certificates, medical reports and other documents related to the treatments.
  • At the time of discharge, obtain the Discharge Certificate or Card.
  • Fill up the claim form. Attach all the relevant proofs of the expenses incurred and the medical bills.
  • The Discharge Certificate or the Discharge Card would also have to be submitted with the claim form and other documents.
  • The insurance company would process documents and on approval will reimburse all medical expenses incurred.

Also Read: 3 Simple Steps for Making an Insurance Claim

Documents required for health insurance claim process.

Here is a list of important documents to be submitted for making your health insurance claim process:

  • Duly filled in medical claim of the insurance company
  • Medical reports and certificates issued by certified medical practitioners
  • Discharge Certificate or Discharge Card
  • All the original medical and hospital bills
  • The prescriptions for medicines and the corresponding cash receipts
  • Investigative medical reports
  • If there have been accidental injuries, FIR copy from the local police authorities. A Medico Legal Certificate would also be required

Knowing the steps of a health insurance reimbursement procedure or cashless claim settlement, along with keeping the afore-mentioned documents handy, simplifies and smoothens the health insurance claim process in India. Keep the list of network hospitals handy for cashless claim settlement. Follow the steps to ensure there is no information or document missing.

Keep the list of network hospitals handy for cashless claim

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