Health Insurance Claim

Most people assume filing a health insurance claim is straightforward until they're stuck with complex documentation. Claim approvals depend heavily on knowing the process. 

41% of claims filed in FY 24-25 were reimbursement-based, often because the treatment wasn't performed at a network hospital or because cashless approval wasn't obtained in time due to incomplete documentation. 

This article explains the types of claims in health insurance, cashless and reimbursement claim procedures, documents required, and which process is better. 

Cashless Claim Procedure

Step 1: Visit a network hospital and head to the insurance desk. For planned hospitalizations, do this at least 48-72 hours before admission. For emergencies, inform the desk as soon as you're admitted, ideally within 24 hours.

Step 2: Share your health insurance card and policy details with the insurance desk. They'll help you fill out the pre-authorization form.

Step 3: The hospital initiates a pre-authorization request on your behalf and sends it to your insurer/TPA for approval. For planned procedures, this happens before admission. For emergencies, it's done during your stay.

Step 4: Your insurer reviews the request against your policy coverage, waiting periods, exclusions, and room rent eligibility. This usually takes a few hours.

Step 5: Once approved, your insurer settles the admissible expenses directly with the hospital. You only pay for non-covered items like consumables, co-payment amounts, or expenses beyond sub-limits.

Reimbursement Claim Procedure

Step 1: Inform your insurer about the hospitalization as soon as possible, ideally within 24 hours for emergencies and at least 48 hours before planned admissions.

Step 2: Proceed with treatment and pay all bills from your pocket. Keep every receipt and document handy.  After discharge, collect the discharge summary, all original bills, payment receipts, investigation reports, and prescriptions.

Step 3: Download the reimbursement claim form from your insurer's website or app, then complete it. Submit the completed form, along with all required documents, to your insurer. Most insurers now accept online submissions.

Step 4: Your insurer reviews the documents, verifies them with the hospital if needed, and processes your claim.

Step 5: Once approved, the reimbursement amount gets credited to your bank account. 

As per IRDAI Guidelines, the insurer should settle within 30 days from receipt of the last necessary document, and if an investigation is needed, up to 45 days. If delayed beyond this: insurer must pay interest at 2% above the bank rate on the payable amount.

Cashless vs. Reimbursement: Which Is Better?

Choose Cashless if:

• The admission is in a network hospital
• Intimation to the insurer/TPA happens within the required timeline
• You’re looking for a convenient experience with minimal payment upfront 
• You want the hospital to handle most of the paperwork

Choose Reimbursement if:

• Treatment happens at a non-network hospital
• You missed the notification deadline
• Cashless request was rejected
• You are okay paying upfront and want the flexibility to choose the hospital and doctor you trust

Documents Required for Claims

To successfully file a health insurance claim, you’ll need to provide certain documents. For details, you can check the infographic below.

Understanding What Qualifies for Claims

Not every hospital visit qualifies for a claim. Here's what actually counts:

• What Qualifies

Medically necessary hospitalization involving active treatment. For instance, an accident leading to a fracture that needs surgery, an appendectomy, and other listed daycare procedures. 

• What Doesn't Qualify

Annual health check-ups, OPD consultations, and preventive tests. These aren't covered under standard policies, but can often be added through optional riders.

• Permanent Exclusions

Cosmetic or aesthetic procedures, self-inflicted injuries, treatment arising from substance abuse, injuries from adventure sports (unless specifically covered), and experimental or unproven treatments. These are mostly excluded across all health policies. 

Why Talk to Ditto for Your Health Insurance?

At Ditto, we’ve assisted over 8,00,000 customers with choosing the right insurance policy. Why customers like Abhinav below love us:

• No-Spam & No Salesmen
• Rated 4.9/5 on Google Reviews by 15,000+ happy customers
• Backed by Zerodha
• Dedicated Claim Support Team
• 100% Free Consultation

Confused about the right insurance? Speak to Ditto’s certified advisors for free, unbiased guidance. Book your call now or chat over WhatsApp, slots fill up fast!

Ditto's Take on Health Insurance Claim

Understanding health insurance claims isn't just about knowing the process; it's about being prepared when life throws you a curveball. The difference between a smooth claim experience and a frustrating one often comes down to choosing the right insurer and policy, plus keeping your documents ready.

Here's what we've observed from helping thousands of customers: pick a policy with a strong network of hospitals in your city. Keep digital copies of your health insurance policy handy. And most importantly, go through your policy document; it makes all the difference between a smooth claim and a rejected one.