How to Claim Health Insurance

Did you know? According to a LocalCircles survey, over 50% of health insurance claims in India were either rejected or only partially approved in the last three years. Even official data from the Insurance Regulatory and Development Authority of India (IRDAI) reveals that in FY 2023–24, insurers rejected 11% of claims outright, with another 6% still pending. This means nearly 1 in 6 claims didn’t result in immediate payout. These numbers highlight a crucial reality: having a right health insurance policy isn’t enough, you must also understand how to claim health insurance correctly to actually benefit from it when it matters most.

If you need help choosing the right policy, feel free to chat with us on WhatsApp or book a free call at a convenient time. No spam — just honest insurance advice.

How to Claim Health Insurance: An Overview

How to Claim Health Insurance: Understanding What Making a Claim Means

A health insurance claim is essentially a formal request you make to your insurance company to receive payment for medical expenses covered under your health insurance policy. When you incur costs due to illness, injury, or a medical condition requiring hospitalization, surgery, or specific treatments, your insurance policy is designed to cover these expenses.

A claim is the process by which you formally inform your insurer of these costs and seek the financial benefits outlined in your policy. It's the action that transforms your insurance coverage from a promise into actual financial assistance, ensuring that eligible medical bills are paid for by the insurer, either directly to the hospital (cashless) or to you (reimbursement). 

How to Claim Health Insurance: Types of Claims

To make a claim in health insurance, there are two primary methods:

1) Cashless Claims: Hassle-Free Hospitalization

Cashless procedures refer to a claim process where the insured individual does not have to pay hospital bills out of pocket. The insurance company directly settles the cost of treatment with the hospital. This facility is only available at hospitals that are part of the insurer’s network or tie-up list.

To avail a cashless claim, the policyholder must present their health insurance policy card or details at the hospital’s insurance or TPA desk. Once the hospital verifies the customer details, they send a pre-authorization request to the insurer. The insurer will then evaluate whether the treatment is covered under the policy. If all conditions are met, the insurer will approve the claim and directly pay the hospital for eligible expenses, based on policy terms such as room rent limits, coverage limits, and any applicable co-payment clauses.

For planned hospitalizations (like scheduled surgeries or procedures), it’s important to inform the hospital and initiate the cashless claim process 24 to 48 hours in advance. This allows enough time for the insurer to review and approve the pre-authorization request before the admission.

In case of emergency hospitalizations, such as accidents or sudden illnesses, the insurer should be notified ideally within 24 hours of admission. Quick intimation is crucial to ensure cashless processing without delays.

If these timelines are not followed, or if the insurer requires additional details (such as missing documents, incomplete medical history, or unclear treatment notes), the cashless request may be denied. In such cases, the claim will not be processed on a cashless basis, instead, the insured person will need to pay the hospital bills and later file for reimbursement by submitting all required documents.

2) Reimbursement Claims: Pay Now, Get Reimbursed Later

A reimbursement claim is a process where the policyholder pays for the medical treatment out of pocket and then requests the insurance company to refund the eligible expenses. This method is used when treatment is taken at a non-network hospital, or if the cashless claim could not be arranged in time such as in emergencies or due to missing pre-authorization.

To make a reimbursement claim, you must collect and submit all original medical documents related to your treatment. This includes the hospital bill, discharge summary, prescriptions, diagnostic reports, doctor’s notes, pharmacy invoices, and your health insurance claim form.

The insurance company will assess your claim based on:

• Your policy coverage (room rent limits, pre/post hospitalization days, exclusions)
• The completeness and correctness of the submitted documents
• Whether the treatment is medically necessary and falls within the covered benefits

Once verified and approved, the insurer will transfer the approved amount directly to your bank account.

Insurers usually set a submission window for reimbursement claims. 

The exact timeline may vary across insurers, but ideally, you should submit your health insurance reimbursement claim within 30 days of discharge. It's best to file it as early as possible. 

If there's a delay beyond this period due to a valid reason, some insurers may still consider the claim on compassionate grounds, though it's not guaranteed. Always check your policy's terms for specific timelines.

Ditto’s advice: Not all hospitals are eligible for insurance claims, even if they provide legitimate treatment. Insurance companies maintain a list of blacklisted or excluded hospitals, which are healthcare providers that have been flagged for irregular practices such as inflating bills, providing substandard care, or engaging in fraudulent activities.

If you receive treatment at a blacklisted hospital:

• Cashless claims will not be honored, even if it was previously on the insurer’s network.
• Reimbursement claims may also be denied, depending on the insurer’s policy and reason for blacklisting.
• You will be required to bear the full cost of treatment out of pocket.

How to Avoid This:

• Always check the latest network hospital list on the insurer's website or app before choosing a hospital.
• In emergencies, contact your insurer or TPA helpline as soon as possible to confirm eligibility.
• If a hospital’s name seems unfamiliar or not listed, verify its status to avoid claim rejection.

Blacklisting can be temporary or permanent and is typically updated without prior public notice. Hence, proactive verification is essential for both cashless and reimbursement claims.

Essential Documents Required for a Smooth Health Insurance Claim

Regardless of whether you are filing a cashless or a reimbursement claim, you must keep the right set of documents ready for a smooth and swift health insurance claim settlement. Missing or incorrect paperwork is a common reason for delays or even rejections. While the exact list can vary slightly between insurers and the nature of the claim, the following are the important documents you will almost always need.

1) For Cashless Claims (primarily required by the hospital for pre-authorization):

• Duly filled and signed health insurance claim form
• Copy of health insurance ID card or policy document
• FIR or Medico-Legal Certificate (MLC) – in case of accidents
• Cancelled cheque or bank details (for reimbursement transfer or refund of deposit amount)
• Pre-authorization form (for cashless claims, submitted by hospital)
• Photo ID and Address Proof: Such as Aadhaar Card, Passport, Voter ID, Driving License of the policy holder and insured patient (If different).

Following documents will generally be provided by the hospital insurance desk to the insurer directly: Discharge summary from the hospital, Final itemized hospital bill, Doctor’s prescription and consultation papers clearly stating the need for admission, Diagnostic reports (blood tests, X-rays, scans, etc.), and Pharmacy bills with valid prescriptions.

2) For Reimbursement Claims (all original documents are typically required for submission to the insurer):

When filing a reimbursement claim, you must submit all original documents to support your request. Insurers require these to validate the authenticity and eligibility of your claim. Always retain photocopies or scanned copies of all documents before submission.

• Completed and Signed Claim Form: Duly filled with all required details.
• Original Hospital Bill: A detailed, itemized bill from the hospital.
• Original Payment Receipts: For all payments made to the hospital.
• Original Discharge Summary: Provided by the hospital at the time of discharge, outlining the treatment, diagnosis, and condition.
• Prescriptions: Original prescriptions for medicines purchased.
• Pharmacy Bills: Original bills for all medicines.
• Original Diagnostic Reports: All reports from tests conducted (e.g., X-rays, blood tests, MRI scans).
• Doctor's Consultation Papers/Referral Letters: If any.
• FIR or Medico-Legal Certificate (MLC): In case of an accident.
• Bank Account Details: A cancelled cheque or copy of your passbook/bank statement for NEFT transfer of the reimbursement amount.
• Photo ID and Address Proof: As mentioned above.

How to Claim Health Insurance: Cashless Procedures – A Step-by-Step Guide

How to claim health insurance through the cashless method is designed to simplify the financial aspect of hospitalization. This process ensures that you don't have to pay large sums out of pocket at the time of treatment, as the hospital directly communicates with your insurer for bill settlement.

Let’s understand how cashless claims work:

Planned Hospitalization: Navigating Pre-Authorization

For medical treatments or surgeries that are planned in advance, the cashless claim process revolves around pre-authorization. Pre-authorization is the process of getting approval from your health insurance company before you undergo planned medical treatment or hospitalization. It confirms that the insurer will cover the costs as per your policy terms.

Choose a Network Hospital: Ensure the hospital where you plan to get admitted is part of your insurer's network. You can usually find this list on your insurer's website or by contacting their customer service.

1. Inform Your Insurer/TPA: Typically, you or the hospital needs to notify your insurance company or their Third-Party Administrator (TPA) typically 24 to 48 hours before the planned admission date.
2. Submit Pre-Authorization Request: The hospital's insurance desk will help you fill out and submit the pre-authorization form to the insurer/TPA. This form will include details about your proposed treatment, estimated costs, and your medical history. You will also need to provide your health insurance ID card and policy number.
3. Await Approval: The insurer/TPA will review the submitted documents and details. They may ask for additional information or clarification. Once approved, they will issue an authorization letter to the hospital, indicating the approved sum and covered treatments.
4. Undergo Treatment: Upon admission, present your health insurance ID card and the authorization letter (if received). Proceed with your planned treatment.
5. Discharge and Settlement: At the time of discharge, the hospital will send the final bill and discharge summary to the insurer/TPA. The insurer will review these and settle the admissible amount directly with the hospital. You will only need to pay for non-covered expenses or deductibles as per your policy.

Emergency Hospitalization: Immediate Claim Procedures

In unforeseen medical emergencies, the pre-authorization process is expedited to ensure immediate medical attention.

1. Rush to a Network Hospital: In an emergency, first prioritize getting the patient admitted to the nearest network hospital.
2. Inform Your Insurer/TPA: You or a family member must inform your insurance company or their TPA within 24 hours of admission. Many policies specify this timeframe strictly. Provide your policy number and initial details of the emergency.
3. Emergency Pre-Authorization: The hospital's insurance desk will quickly send the emergency pre-authorization request to the insurer/TPA. They will provide the necessary medical details and initial estimated costs.
4. Receive Treatment: While awaiting authorization, the hospital will begin necessary emergency treatment. Life-saving measures are never delayed for authorization.
5. Follow-up for Approval: The insurer/TPA will review the emergency request. Once approved, an authorization letter will be sent to the hospital.
6. Discharge and Settlement: Similar to planned hospitalization, at discharge, the hospital will send the final bill and discharge summary. The insurer will then settle the admissible amount directly with the hospital, and you pay only for non-covered items.

Ditto’s advice: Even in emergencies, keeping your health insurance ID card and policy details handy is crucial for quick coordination with the hospital and insurer. If cashless approval is denied for any reason, you will have to pay the bills and apply for reimbursement later.

Read our detailed guide on how to choose a health insurance policy wisely to ensure you are well-prepared from the start.

How to Claim Health Insurance: Reimbursement – Detailed Process

The reimbursement claim process is useful when you get treated at a non-network hospital, or if the cashless facility isn’t available or denied. In this method, you pay for your treatment upfront and later claim the expenses from your insurer. To ensure your reimbursement claim is processed smoothly, you need to follow a specific procedure and submit the required documents within the set timeframe.

Step 1: Choose Any Hospital (Network or Non-Network)

You can receive treatment at any hospital of your choice, whether it’s part of the insurer’s network or not. However, if it’s a non-network hospital, you won’t be eligible for cashless claims and will have to pay all expenses out of pocket initially and then file for reimbursement.

Note: In a reimbursement claim, you must pay all hospital expenses out of pocket. Whether the hospitalization is planned or due to an emergency. Unlike cashless claims, pre-authorization or advance intimation to the insurer is not mandatory, though informing them early is still advisable for smoother processing.

Once treatment is complete and you are discharged, you need to submit the claim along with all required original documents: hospital bills, prescriptions, discharge summary, and claim form, within the timeframe specified in your policy.

However, one crucial condition is that the hospital should not be blacklisted by your insurer. Claims from blacklisted hospitals are typically rejected, regardless of the treatment or documentation.

Step 2: Collect All Original Medical Documents

Once the treatment is complete, you must collect and preserve all original documents, such as:

• Final hospital bill
• Discharge summary
• Prescription and diagnostic reports
• Payment receipts
• Investigation reports
• Medicine bills with prescriptions
• Duly filled claim form
• Doctor’s certificate, if required

Step 3: Fill Out the Reimbursement Claim Form

Obtain the reimbursement claim form from your insurer’s website or branch office. Fill it carefully, providing accurate personal details, policy number, treatment information, and bank details for payment.

Step 4: Submit the Claim Package

Submit the filled claim form along with all the collected original documents to your insurance company or their designated TPA. This can usually be done via:

• Offline: Courier or registered post to their claims processing office. Always keep a tracking number.
• Offline (In-person): Hand delivery at a branch office, ensuring you get an acknowledgment receipt.
• Online: Uploading scanned copies of all documents through the insurer's online portal or mobile app. Even if you submit online, you must keep the original physical documents safe, as the insurer may request them for verification.

Keep photocopies of everything for your records.

Timeframe: Most insurers require that reimbursement claims be submitted within 30 days from discharge. Always check your policy terms to avoid missing the deadline and try to submit as early as possible.

Step 5: Claim Processing and Verification by the Insurer

Once all your documents are received, the insurance company or TPA will begin the process of verifying your claim. They will review all the submitted documents, cross-reference them with your policy terms and conditions, and check whether the treatment and costs fall under your policy coverage. They may contact you or the hospital for additional information or clarification if anything is missing or unclear.

Step 6: Claim Approval and Reimbursement

Once approved, the insurer will transfer the eligible reimbursement amount to your bank account. The amount paid may be adjusted for co-payments, policy limits, deductibles, sub-limits, or exclusions, if applicable. Thereafter, the insurer will send you a communication (SMS/email/letter) detailing the approved amount and the settlement.

Types of Hospitalizations that Can be Claimed Under Health Insurance

Health insurance policies are designed to cover a wide array of medical scenarios requiring hospitalization, providing crucial financial protection. It is important to understand not just what is typically covered, but also what specific situations or treatments might be excluded. This clarity helps in effective financial planning and prevents surprises during a claim.

Common Hospitalization Scenarios Covered by Insurance

Health insurance generally covers expenses related to a broad spectrum of medical needs that necessitate at least 24 hours of hospitalization. While specific inclusions can vary slightly between policies, common scenarios that are covered include:

• Illness-Related Hospitalization: Coverage for expenses arising from hospitalization due to various illnesses such as infections, organ diseases, respiratory conditions, cardiovascular issues, and more. This includes room rent, nursing charges, doctor's fees, diagnostic tests, medicines, and surgical charges.
• Accident-Related Hospitalization: Costs incurred due to hospitalization following an accident, including injuries that require immediate medical attention, surgery, or prolonged recovery.
• Pre-Hospitalization Expenses: Medical expenses incurred for tests, consultations, and medications for a specific period (e.g., 30-90 days) before the actual hospitalization, provided they are related to the condition leading to the hospitalization.
• Post-Hospitalization Expenses: Costs incurred for follow-up consultations, diagnostic tests, and medicines for a specific period (e.g., 60-180 days) after discharge from the hospital, provided they are related to the treated condition.
• Daycare Procedures: Coverage for advanced medical procedures that require less than 24 hours of hospitalization due to technological advancements. Examples include cataract surgery, chemotherapy, dialysis, and certain minor surgeries.
• Maternity Coverage Expenses: Many policies offer coverage for maternity-related expenses, including delivery (normal or C-section), pre-natal, and post-natal care, often after a specific waiting period.
• Organ Donor Expenses: Coverage for medical expenses incurred by the organ donor for the organ harvesting procedure during a transplant.
• Ambulance Charges: Costs incurred for emergency ambulance services to transport the insured to the hospital.

Exclusions: What Your Policy May Not Cover

While comprehensive, health insurance policies always come with certain permanent exclusions, that are conditions or treatments not covered. Be aware of these to avoid claim rejections. Common exclusions include:

• Pre-existing Diseases (PEDs): Diseases diagnosed before purchasing the policy are typically excluded for an initial waiting period (2-3 years) before they become covered.
• Specific Diseases/Treatments: Certain ailments like cataracts, hernia, joint replacement surgery, etc., may have specific waiting periods (2 years) before they are covered.
• Consumables and Non-medical Expenses: Items like gloves, syringes, and administrative charges are usually not covered unless specified or available as add-ons.
• Treatments in Blacklisted Hospitals: Claims from hospitals blacklisted by the insurer are not admissible.
• Cosmetic Surgery: Procedures primarily for aesthetic enhancement are generally not covered unless necessitated by an accident or severe medical condition.
• Dental Treatment: Routine dental check-ups, fillings, and root canals are usually excluded unless requiring hospitalization due to an accidental injury.
• Outpatient Department (OPD) Expenses: Consultations, tests, and medicines that do not lead to hospitalization are usually not covered unless specified in an add-on or specific OPD plan.
• Self-inflicted Injuries: Injuries resulting from suicide attempts, self-harm, or substance abuse are typically excluded.
• War and Nuclear Perils: Damages or injuries arising from acts of war, invasion, or nuclear contamination are not covered.
• Hazardous Sports/Activities: Injuries sustained while participating in dangerous sports or activities (e.g., skydiving, mountaineering) may be excluded.
• Unproven/Experimental Treatments: Treatments that are not scientifically proven or are experimental in nature are generally not covered.
• Treatment Abroad: Medical treatment received outside India is typically not covered unless specified in a global coverage add-on.

How to Claim Health Insurance: The Things to Keep in Mind to Avail it

To make a claim successfully, you need to understand your policy well and keep all your medical records organized.

Understanding Your Policy Terms and Conditions

Your health insurance policy document is a legal contract, and thoroughly understanding its terms is the bedrock of a successful claim. Don't just file it away; read it carefully to grasp:

• Coverage Details: What exactly is covered, including specific illnesses, treatments, and limits for room rent, ICU charges, etc.
• Waiting Periods: Understand the initial waiting period (for all illnesses), specific waiting periods (for named diseases), and the waiting period for pre-existing diseases. Claims made during these periods will be rejected.
• Sub-limits: Be aware of any caps on specific expenses like room rent restriction, specific procedures, or doctor's fees. Exceeding these limits means you pay the difference.
• Deductibles and Co-payments: Know if your policy has a deductible (an amount you pay before the insurer steps in) or co-payment (a percentage of the claim you must bear), avoid both if possible.
• Exclusions: Be fully aware of what your policy does not cover, as mentioned in the previous section.
• Claim Procedure and Timelines: Familiarize yourself with the exact steps for both cashless and reimbursement claims, along with the strict timelines for intimation and document submission.

Importance of Timely Intimation

Notifying your insurance company or their Third-Party Administrator (TPA) about a hospitalization is a critical step that cannot be overlooked.

• Cashless Claims: For planned hospitalizations, pre-authorization must be sought 24-48 hours in advance. For emergencies, intimation is typically required within 24 hours of admission. Delay in intimation can lead to cashless approval denial, forcing you into a reimbursement process.
• Reimbursement Claims: After discharge, you need to submit the claim with all original documents such as bills, prescriptions, discharge summary, and the completed claim form, as early as possible or within the deadline set by your policy.

Keeping Accurate Records

Maintaining meticulous records is a simple yet incredibly powerful habit that can prevent many claim-related headaches.

• Policy Documents
• Medical Records (discussed in above section in detail)
• Communication Records: Keep a record of all communication with your insurer or TPA, including dates of calls, names of representatives, and any reference numbers provided. For email communication, save all threads.
• Photocopies of Submissions: Before submitting any original documents for a reimbursement claim, always make and keep photocopies for your own records.

Top Reasons Why Health Insurance Claims Get Rejected

A health insurance claim rejection can be extremely frustrating. Especially when you're already dealing with medical issues. While insurers strive for fair processing, certain common mistakes or policy clauses frequently lead to claims being rejected.

How to Avoid Claims Rejections: Mistakes to Avoid

Many claim rejections stem from errors or oversights by the policyholder. Here are the most frequent ones:

• Delay in Intimation: Failing to inform your insurer or TPA about hospitalization (planned or emergency) within the specified timeframe is a major reason for denial.
• Incomplete or Incorrect Claim Form: Errors, omissions, or discrepancies in the claim form, such as wrong policy numbers, incorrect dates, or mismatched information, can lead to rejection.
• Missing or Unoriginal Documents: Submitting incomplete sets of documents, unreadable copies, or photocopies when originals are required are common reasons for claims being put on hold or rejected.
• Non-Disclosure of Pre-existing Diseases: If you intentionally or unintentionally fail to declare pre-existing medical conditions at the time of purchasing the policy, any claim related to those conditions can be rejected.
• Treatment at Non-Network Hospital (for cashless): Attempting a cashless claim at a hospital not listed in your insurer's network will result in denial; you would then need to switch to a reimbursement claim.
• Claiming During Waiting Periods: Submitting a claim for an illness or procedure that falls within the initial waiting period, specific waiting period (for named diseases), or pre-existing disease waiting period will lead to rejection.
• Policy Lapsed: If your policy has lapsed due to non-payment of premiums, it will not provide any coverage, and claims will be rejected.
• Fraudulent Claims: Any attempt to make a false or exaggerated claim, or provide misleading information, will result in outright rejection and potential legal consequences.
• Mismatch in Medical Records: Inconsistencies between the diagnosis, treatment, and medical reports from the hospital and the information provided in the claim form can raise red flags.

Why Approach Ditto for Health Insurance?

At Ditto, we’ve assisted over 7,00,000 customers with choosing the right insurance policy. Why customers like Deepak below love us:

✅No-Spam & No Salesmen

✅Rated 4.9/5 on Google Reviews by 12,000+ happy customers

✅Backed by Zerodha

✅100% Free Consultation

You can book a FREE consultation. Slots are running out, so make sure you book a call now!

Conclusion

Successfully managing how to claim health insurance is not just about knowing the steps, it’s about being prepared. Read your policy carefully, follow the correct procedures, and always keep records organized. Whether it’s a cashless or reimbursement claim, understanding the process helps avoid delays or denials. When you know how to claim health insurance the right way, you make sure you get the financial support you’re entitled to, right when you need it the most. 

Frequently Asked Questions (FAQs) on How to Claim Health Insurance