When you choose a health insurance plan for yourself and your family, your primary expectation is that your policy will come to your financial rescue when you need it the most. So, you need a health insurance provider and policy that offers a smooth claim settlement process and quick disbursal of the billed amount. Consequently, you need to be aware of how to claim your respective health insurance plan.

How to make a claim in health insurance?

Irrespective of which health insurer you go ahead with, the involved claim process is more or less the same. The only thing that you need to remember is that the claim process and documentation vary slightly, based on whether you have chosen a cashless mode of claim settlement or reimbursement.

A. CASHLESS HEALTH INSURANCE CLAIM PROCESS

Ravi holds a ₹20 lakhs health insurance plan. He has a scheduled Appendectomy and approaches a partner hospital for the procedure. He wants to go ahead with a cashless claim settlement, and thus he follows up with these steps -

STEP 1: He informs his health insurance provider/TPA (Third Party Administrator)  about the procedure. (He knows, the window for this notification is -  within 24 hours (in case of emergency) of hospitalisation or 72 hours (in case of scheduled treatments) before the hospitalisation).

STEP 2: He submits his policy number and health insurance card to the health insurance desk of his hospital.

STEP 3: He fills out the insurance form and submits it to his insurer/TPA.

During his hospitalisation, the hospital desk reaches out to his insurer and informs them about the ongoing procedure. They also send all the invoices to the insurer, who then verifies the bills and disburses the invoiced amount.

Since this is a cashless transaction to settle claims, no further involvement is required from Ravi’s end.

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What are the documents required to file a cashless claim in health insurance?

When filing a cashless claim, you, the policyholder will need to submit the following documents -

  • ID proof like - voter ID, Aadhar card, Driver's license
  • The pre-authorization form for procedures that require prior approval/clearance from your health insurance provider
  • The doctor’s prescription that mentions the hospitalization and the specific procedure/surgery.
  • The filled-out claim form Health insurance policy details including information like the insurer’s name, policy number, etc.

B. REIMBURSEMENT HEALTH INSURANCE CLAIM PROCESS

Cashless is a preferred mode of claim settlement among all policyholders. However, there are certain cases during which reimbursement is the only available option. So, what exactly are these cases?

CASE 1: If you are undergoing a medical treatment/procedure in a non-network hospital.

CASE 2: If you have failed to inform your insurer about the hospitalization within the pre-decided window of notification.

CASE 3: If the initial ailment is not covered under your plan, but the same policy covers its follow-up treatment/procedure.

Given that you had to opt for a reimbursement claim settlement, here is how you can file the claim -

STEP 1: Inform your health insurer/TPA about the hospitalisation, preferably before getting admitted or at the most within 24 hours of being hospitalised.

STEP 2: Collect all the invoices generated by your hospital.

STEP 3: Pay the hospital bill from your pocket.

STEP 4: Post-discharge, file the claim settlement form and submit it to your insurer/TPA.

STEP 5: Once the insurer reaches out to you, submit the documents.

STEP 6: Insurer/TPA cross-verifies the documents and reaches out to the concerned hospital desk about the same.

STEP 7: Insurer disburses the claim amount.

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What are the documents required to file a reimbursement claim in health insurance?

When filing for a reimbursement claim and waiting on your insurer’s response, here are the documents that you must collect and collate -

  • Relevant ID proof
  • Pre-authorisation form
  • Original claim form
  • Prescriptions that comprise the doctor’s advice to undergo the medical procedure.
  • Any invoice involved in the investigation of the ailment
  • Medical reports that confirm your prognosis.
  • All invoices that are generated by the hospital desk.

Now, unless -

  • Your room rent exceeds the capping specified in your policy wording, and/or
  • You have a co-payment clause in your plan, and/or
  • Your surgery/medical procedure has a sub-limit on it, as per your health insurance plan, and/or
  • Your plan doesn’t cover any medical/surgical equipment (otherwise called consumables), and/or
  • Your current coverage falls short when paying off the billed amount

- your health insurer will pay off the entire claim amount. However, there are certain cases in which your claim might get rejected. Under such circumstances, here is what you should do.

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What to do if your claim gets rejected?

STEP 1: Try and understand why your health insurance claim was rejected.

STEP 2: Talk to your insurer about re-applying for your claim.

STEP 3: Collect the required documents that would be necessary to rectify any issues with your claim.

STEP 4: Re-apply for the claim.

In case these steps fall short of helping you with your claim, you can always approach the Ombudsman forum and request an intervention. However, if this step fails, your last resort would be to file a report at the Consumer Court with legal counsel backing you up.