Understanding how to claim health insurance: End-to-End Process

The primary reason for investing in health insurance is its coverage for medical expenses. You can make the most of the coverage benefits by making a claim. The insurer will then verify the eligibility of the claim and settle the incurred expenses.

Cashless and reimbursement are the two types of claims you can make. The steps of the health insurance claim process differ depending on the claim type.

The article will look at insurance claim types, steps and things to remember for a hassle-free claim process.

Understanding health insurance claim types

There are two ways you can make a claim under a health insurance policy: cashless and reimbursement.

• Cashless Claims Everywhere

If you receive treatment at either a network or a non-network hospital, you can file a cashless claim. In this case, the insurer directly settles the medical expenses with the hospital, so you don’t have to pay out of pocket initially.

• Reimbursement

If you are treated at a non-network hospital, you must first pay the medical expenses out of pocket. Then, you can later make a health insurance reimbursement claim to your insurer.

Hospitalisation types eligible for health insurance claim

There are two types of hospitalisation for which you can claim health insurance.

• Planned

In this type of hospitalisation, you know in advance about the treatment. For example, you could be undergoing surgery for a known health condition. You must inform the insurer two to four days before a planned hospitalisation. 

• Emergency

This type of hospitalisation is unplanned. For example, in the unfortunate event of an accident or a medical emergency, you may have to seek treatment. You must inform the insurer within 24 hours of admission for an emergency hospitalisation.

Step-by-step process of raising a health insurance claim

Here are the steps involved in the health insurance claim process, depending on the claim type.

1. Cashless Claim

• For a cashless claim, you can get treated at a network or a non-network hospital. You must inform the insurer 48 to 72 hours before hospitalisation, as per your policy terms.
• Contact the hospital’s insurance desk, get the required pre-authorisation form, and fill it out carefully.
• Typically, the healthcare provider takes the initiative of submitting the form to the insurer.
• The insurer will review the request’s eligibility and approve it according to your policy terms.
• The insurer will directly settle the expenses with the hospital. Please note that at the time of discharge, you may have to pay for expenses like consumables that are not covered by your insurance plan.
• Insurers are required to settle claims within three hours of receiving them from the hospital at the time of discharge. Additionally, IRDAI mandates a one-hour timeframe for processing cashless claim requests during admission. 
• You can file a claim for a single hospital stay using multiple health insurance policies. For instance, if you have two health plans worth ₹4 lakh and ₹10 lakh each, and your hospital expenses total ₹12 lakh, you can leverage both policies to cover the claim.

2. Reimbursement Claim

• Inform the insurer about the treatment and hospital (It could be a network/non-network hospital).
• Get treated at the hospital. 
• At the time of discharge, settle the medical bills. Ensure you collect documents like discharge summaries, prescriptions and bills.
• Fill out the insurance claim form and submit the request to the insurer along with the relevant hospitalisation documents.
• The insurer will verify your claim according to your health insurance terms.
• If approved, the insurer will reimburse your medical expenses.
• You can file a claim for a single hospital stay using multiple health insurance policies. For instance, if you have two health plans worth ₹4 lakh and ₹10 lakh each, and your hospital expenses total ₹12 lakh, you can use both policies to cover the claim.

Documents required when claiming health insurance

Here are some documents you should have handy when making a health insurance reimbursement or cashless claim.

• Doctor consultation papers
• Duly filled insurance claim form
• Diagnostic reports
• Prescriptions
• Discharge summary
• A Medico Legal Certificate (MLC) and/or First Information Report (FIR) in case of an accident.
• Medical bills (stamped and signed by hospital authorities)
• Payment receipts

Things to remember about the health insurance claim process

• Whether it is a planned or emergency hospitalisation, inform the insurer as soon as possible.
• Most insurers mention the period within which you must raise a claim and submit the required documents. According to IRDAI, the insurer must consider claims raised after this period, but the insured must have a valid reason for the delay.
• Ensure the insurance claim form is duly filled. Any mistakes in the form could lead to your claim being denied.
• When purchasing a health policy, look for a provider with a good claim settlement ratio in health insurance. The CSR percentage represents the number of claims settled against the number of claims received. The higher the percentage, the more reliable the insurer is.

Key Takeaways

Under health insurance plans, you can make cashless and reimbursement claims. Depending on the claim type, the insurer will settle with the network/non-network hospital or reimburse your expenses.

You must inform the insurer beforehand for planned hospitalisation and within 24 hours of emergency hospitalisation.

When making claims, fill out the required forms carefully and submit the relevant documents within the stipulated timeframe. Using platforms such as PhonePe can simplify the process of selecting and buying the right health insurance.