Introduction
Medical emergencies may occur at any moment, and health insurance gives financial protection by covering medical bills. Yet, numerous people get confused with the claim procedure and end up delaying the process unnecessarily or even having their claims rejected. By knowing your policy, keeping papers in proper order, and going through proper steps, you can make sure of a stress-free and hassle-free health insurance claim process.
This guide will take you through all you need to know about filing a successful claim, such as various types of claims, step-by-step processes, documents needed, pitfalls to avoid, and tips to speed up the process.
Understanding Your Health Insurance Policy
It is important to fully read your health insurance policy before making a claim. Knowing the coverages, the exclusions, and the term and conditions will save you from surprises when you make the claim.
Important Points to Read in Your Policy:
- Sum Insured – The maximum amount the insurer can pay for medical bills in a policy year.
- Coverage Details – Clarify if your policy includes hospitalization, pre- and post-hospitalization expenses, daycare procedures, ambulance fees, and other mediclaim expenses.
- Inclusions & Exclusions – All policies have a list of treatments and ailments included, as well as exclusions like cosmetic surgeries, dental care, and pre-existing conditions (within the waiting period).
- Waiting Periods – Certain diseases, such as pre-existing diseases or maternity benefits, have a waiting period before the coverage is initiated.
- Network Hospitals – If your insurance company has arrangements with certain hospitals, you can get cashless treatment at those hospitals. Treatment at non-network hospitals involves reimbursement claims.
- Co-payment & Sub-limits – Certain policies ask you to pay a portion of the claim amount (co-payment), and some treatments are subject to a sub-limit on the amount paid.
- Claim Intimation Timeline – Every insurer has a specified time limit within which a claim should be intimated, particularly for emergency hospitalization.
Types of Health Insurance Claims
Health insurance claims can be generalized into two types:
1. Cashless Claims
A cashless claim enables you to get treatment without paying at the time of treatment at a network hospital. The insurer settles the bill directly with the hospital, so it is a trouble-free process.
Steps to Make a Cashless Claim:
- Notify the Insurer – For a scheduled hospitalization, notify your insurance company at least 48-72 hours prior to hospitalization. In the event of an emergency, notify your insurance company within 24 hours of hospital admission.
- Show Your Health Card – When in the hospital, present your health insurance card and fill out the pre-authorization form found at the insurance counter of the hospital.
- Verification & Approval – The insurer receives the pre-authorization request sent by the hospital and approves the treatment under terms of policy.
- Receive Treatment – After approval of the claim by the insurer, you are free to undergo treatment without spending a single penny except for excluded expenses.
- Final Settlement – The hospital sends final bills to the insurer after discharge, and the insurer pays the amount directly to the hospital.
2. Reimbursement Claims
In case you receive treatment from a non-network hospital, you have to pay the bills first and then claim reimbursement from your insurer.
Steps to Make a Reimbursement Claim:
- Pay for the Treatment – Pay the hospital bills on discharge and gather all the receipts.
- Gather All Necessary Documents – Get discharge summaries, physician prescriptions, diagnostic reports, pharmacy bills, and payment proofs.
- Fill Out the Claim Form – Download the claim form from your insurer’s website, fill it, and attach all documents required.
- Submit the Claim – Submit the completed form and supporting papers to your insurer within the stated time limit.
- Claim Processing & Approval – The insurance company processes your claim, checks the documents, and credits the amount of reimbursement in your bank account after approval.
Important Documents to be Submitted in a Health Insurance Claim
Proper documentation plays a vital role in ensuring your claim gets processed quickly. Below is a checklist of necessary documents:
- Duly filled claim form (available on the insurer’s website)
- Health insurance policy details (policy number, coverage details)
- Hospital admission and discharge summary
- Original hospital bills, prescriptions, and diagnostic reports
- Pharmacy bills with the doctor’s prescription
- Payment receipts of hospital bills
- Proof of identity (Aadhaar, PAN card, etc.)
- Cancelled cheque (in case of reimbursement claims)
- Pre-authorization approval letter (in case of cashless claims)
Errors to Avoid When Filing Claims
Most claims are denied or delayed by committing simple errors. Some of these common mistakes include:
- Not Informing the Insurer in Time – Late intimation may lead to rejection of the claim.
- Submitting Incomplete or Wrong Documents – Omitted reports, wrong information, or incomplete forms may cause delays in the claim.
- Seeking Treatment at a Non-Network Hospital for Cashless Claims – If you opt for a non-network hospital, you will not be able to take advantage of cashless treatment.
- Claiming for Non-Covered Expenses – Some expenses, such as consumables or administrative fees, are not covered.
- Overlooking the Policy’s Terms & Conditions – Failure to read policy exclusions and limits can result in undesired claim rejection.
How to Expedite Your Health Insurance Claim
In order to have a quick and hassle-free claim process, bear these tips in mind:
- Maintain a digital version of all documents – Scan receipts and medical reports and upload them to prevent loss.
- Utilize the insurer’s mobile app – Most insurers provide claim tracking, document upload, and status updates through their apps.
- Reply to questions in a timely manner – If the insurer requests more information, respond promptly.
- Regular follow up – Look up the status of your claim on the website of your insurer or speak to customer care for information.
What To Do If Your Claim Is Refused?
If your claim is refused, don’t be alarmed. Try these steps to get the issue sorted out:
- Know the Reason – The insurance company will give you a reason for denial. It could be due to missing papers, policy limitations, or inaccuracies.
- Appeal the Decision – If you think your claim has been unjustifiably denied, file an appeal with the required supporting documents.
- Get in touch with the Insurance Ombudsman – In case the insurer fails to redress, one can bring the matter to the Insurance Ombudsman for mediation.
- Make a complaint with IRDAI – The Insurance Regulatory and Development Authority of India (IRDAI) assists customers in case of grievances with the insurers.
Other Things to Keep in Mind for a Seamless Health Insurance Claim Experience
Though the fundamental claim process is required, there are a number of other aspects that may determine how freely and easily your claim is settled. Ranging from selecting the best insurance company to knowing the reasons for rejection of your claim, here are other things you need to keep in mind for a seamless experience.
1. Selecting the Best Health Insurance Company
Ease in availing the insurance benefits considerably depends on which insurance company you opt for. While choosing your health insurance plan, take note of:
A. Claim Settlement Ratio (CSR)
The claim settlement ratio is the proportion of claims an insurer settles successfully out of total claims received in a year. A high CSR (more than 90%) means that the insurer has an excellent record of processing and settling claims in a timely manner.
B. Turnaround Time for Claim Processing
Some insurers process claims faster than others. Look for companies that offer quick claim settlements and have a good reputation for speed and efficiency.
C. Network Hospitals Coverage
A wider network of cashless hospitals increases your chances of receiving medical treatment without out-of-pocket expenses. Always check the list of hospitals tied up with the insurer before purchasing a policy.
D. Customer Support Quality
A good and responsive customer support team can make a big difference when you are in need of assistance while filing a claim. Make sure that the insurer provides 24/7 support through phone, email, or mobile apps.
2. Pre-Hospitalization and Post-Hospitalization Claims
Most insurance policies not only cover hospital expenses but also include pre-hospitalization and post-hospitalization expense claims. These are:
- Pre-hospitalization charges: Doctor visits, diagnostic procedures, and medicines spent prior to hospitalization (generally covered for 30–60 days prior to admission).
- Post-hospitalization charges: Follow-up consultations, medicines, rehabilitation, and tests needed after discharge (generally covered for 60–90 days after discharge).
For these claims, retain all medical bills, prescriptions, and diagnostic reports as they will be needed for reimbursement.
3. Daycare Procedures and OPD Claims
Some medical treatments need not keep one in a hospital for the full duration but are done and gone within just a few hours. These procedures are referred to as daycare procedures and can comprise:
- Cataract operation
- Chemotherapy and radiotherapy
- Dialysis
- Angiography
- Minor surgical procedures such as tonsillectomy
Most contemporary health insurance policies also pay for outpatient department (OPD) charges, such as doctor visits, diagnostic tests, and pharmacy costs. If you have a policy that pays for OPD charges, don’t forget to claim them by filing legitimate receipts.
4. Critical Illness and Specialized Coverage Claims
Some health insurance policies provide critical illness coverage for critical diseases like:
- Cancer
- Stroke
- Kidney failure
- Heart attack
- Major organ transplants
Unlike normal health insurance claims, critical illness insurance pays a lump sum amount on diagnosis, which can be utilised for treatment, lifestyle modifications, or replacement of income. Always enquire about the waiting period and exclusions prior to making a claim under such policies.
5. Maternity and Newborn Baby Coverage
Many family health insurance policies include maternity benefits, covering:
- Delivery expenses (normal or C-section)
- Pre-natal and post-natal care
- Newborn baby coverage for the first 90 days
- Vaccination costs
Maternity benefits, though, typically involve a 9-month to 4-year waiting period, and hence it makes sense to prepare in advance. Always read policy conditions before initiating a claim under maternity benefits.
6. Health Insurance Claim for COVID-19 and Pandemic-related Illnesses
With the outbreak of pandemics such as COVID-19, most insurers have launched special health coverage for pandemic treatment. While claiming insurance for COVID-19 or infectious diseases, make sure you:
- Verify if home treatment is reimbursed (most policies permit claims for oxygen therapy, surveillance, and teleconsultation).
- Provide a COVID-19 test report and hospitalization documents.
- Look for quarantine coverage (some policies include coverage for costs incurred in institutional quarantine).
Government-backed medical schemes such as Arogya Sanjeevani Policy and Corona Kavach Policy offer extra coverage for pandemic-related care.
