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Decode The Health Insurance Claim Process

You must make a health insurance claim to your insurance provider in order to use the services and health insurance benefits that are covered by your policy. There are two methods to submit a claim for health insurance a reimbursement claim and a cashless claim.

Process for cashless claims

The insured must receive treatment in a hospital that has been empanelled in order to use the cashless claim facility.

Whether the treatment is planned or unplanned, the claims procedure changes at a cashless network hospital. In a hospital with a cashless network, unexpected medical care is typically only provided in an emergency.

The cashless network’s claims procedure for planned medical treatment:

The following describes the cashless claims procedure for planned treatment:

  • At least five days prior to the scheduled treatment date, you must mail or email the cashless claim form to your insurance.
  • When the insurance provider receives your cashless health insurance claim form, they will notify the hospital.
  • A letter of confirmation will be sent to you, and it will be good for seven days starting from the date of issuance.
  • Before being admitted, submit the confirmation letter and health card. The insurance provider will cover your medical costs.

Health insurance claims process for emergency treatment at the cashless network

The following is the cashless claims procedure for emergency care:

  • Within 24 hours after being hospitalised, you must tell your insurance company or third-party administrator. You will receive a claim notification and reference number.
  • Your cashless claim form should be completed and sent by the hospital to your insurer.
  • After receiving your cashless claim form, the insurance company will send an authorisation to the hospital.
  • The insurance provider will cover your medical costs. You will be notified via both your registered mobile number and email address if your claim is denied.

Reimbursement claim procedure

If the policyholder chooses to visit a hospital that is not on the insurer’s list of participating hospitals, a reimbursement claim for a health insurance plan may be issued. The cashless claim facility is not applicable in this situation. As a result, before requesting reimbursement, the insured must pay all of his or her medical bills as well as any additional expenses related to hospitalisation and treatment. *

The following is the reimbursement claim procedure:

  • Check the information listed on your medical bill.
  • After being released from the hospital, you must deliver the appropriate documentation to the insurance provider or third-party administrator.
  • The third-party administrator or insurance provider will examine your documents. It may take up to 21 days to review your paperwork and handle the payment.
  • If your insurer has a question or if your claim is denied, you will be contacted.

When submitting cashless claims or reimbursement claims, the following documentation is necessary:

  • Medical ID
  • A properly completed claim form, together with a signed medical certificate or form.
  • Original discharge report or card obtained from the hospital.
  • Every invoice and receipt (original)
  • Cash and prescription memos from hospitals and pharmacies.
  • Investigation findings
  • The FIR or Medico Legal Certificate (MLC) is needed if it is an accident case.

FAQs

  • What forms of health insurance claims are there?

There are two ways to submit a claim for your health insurance plan: cashless claims and reimbursement claims.

  • What distinguishes reimbursement claims from cashless claims?

In a cashless claim, the insurance provider will cover your medical costs at the time of your discharge. You can pay for your medical expenses in a reimbursement claim and then request repayment later.

  • How long does it take to process a reimbursement claim?

It could take the insurance company up to 21 days to review your paperwork and handle the payment.

* Standard T&C Apply

Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.

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