Health Insurance Claim

When a health insurance policyholder would like to obtain services covered by their Health Insurance Policy, s/he needs to submit a Health Insurance Claim. 
The policyholder can opt for either:

1. A direct claim settlement via cashless treatment.
   or
2. Reimbursement for the expenses made on medical grounds. 

For cashless services, the insurance provider has to be informed accordingly. 
In case of reimbursement, a claim form must be filled and submitted.

Types of Health Insurance Claim

The primary reason for individuals and families to invest in health insurance plans, is to have financial security and support if or when the need arises. For quick and hassle-free settlement of medical costs incurred, the health insurance policy claim process must be initiated. 

There are two ways to claim a health insurance policy:

Cashless Claims:

A Cashless claim is useful, and preferred by many, because all the bills are settled directly between the insurance company and the hospital. 
However, to avail this benefit, the policy holder should have used the services of only those hospitals affiliated to the insurance provider.

Reimbursement Claims:

A reimbursement claim is useful and preferred by many others because the insurance company reimburses the expenses directly to the policy holder, after the policyholder has already made the payments to the hospital. 

In this kind of claim, this reimbursement facility is valid at affiliated as well as non-affiliated hospitals.

The Process for Authorization of Health Insurance - Cashless Claim

1. The policy holder or their attendant informs the insurer i.e. Insurance Company.
2. The company verifies the policy, the claim, the validity and the amount covered by the policy.
3. The document is pre-authorised by a field doctor, sent by the insurance company, to cross check the claim. 
4. Once the claim is verified, the insurance company’s medical processes the policy holder’s claim as per their terms and conditions.

Important Conditions to Avail Health Insurance Claim:

• In case the claim details are incomplete, the authorisation can be cancelled.
• It is important that claims are filed within 30 days from the discharge date, 
• In case of non-payable items, the policyholder is liable to bear the expenses. 
• In order to claim the entire post-hospitalisation expense, it is important to submit all relevant documents within 30 days of being discharged. 

Health Insurance Claim Process

Claim Settlement Process for Cashless Claims: To avail cashless claim facility for a health insurance policy, it is necessary to take the following steps:

• First go to the insurance help desk at the hospital.
• For identification, the ID card of the policy holder that has been given by the health insurance provider must be presented at the desk.
• After verification by the hospital staff, a pre-authorization form will be submitted by them to the health insurance company of the insured person.
• All the documents submitted are checked, authenticated and reviewed, before processing the claim as per the terms and conditions of the health insurance policy.
• A health insurance company may also send their field doctor to ease the hospitalization process of the insured.
• The claim is settled after all formalities are completed, as per the terms and conditions of the policy.

There are 2 types of Health Insurance Cashless Claim:

Planned Hospitalization

If a policyholder is aware of their hospitalisation in advance, for e.g. Surgery, s/he can opt for planned hospitalization. 
To avail claim cashless treatment in such a scenario:

1. Contact the toll-free helpline number of the health insurance policy sufficiently prior to the hospitalisation.
2. Email/ fax a scanned pre-authorization form that needs to be filled by the hospital, to the email address or fax number of the health insurance provider.
3. Contact the toll-free helpline number of the health insurance policy provider beforehand.

Emergency Hospitalization

A sudden emergency, which needs hospitalization, is also covered by insurance providers. It can be a lifesaver if the insured has an accident, or is dealing with an illness that needs immediate hospitalization.

1. Once the insured patient has been admitted to the hospital, his/her family must contact the health insurance provider on their toll-free number.
2. Email/ fax a scanned pre-authorization form that needs to be filled by the hospital, to the email address or fax number of the health insurance provider, within 24 hours of admission.

Note: The email addresses, toll-free numbers and the numbers on which the fax must be sent, are generally mentioned on the policy documents and/or on the insurance ID card of the policy holder.

Claim Settlement Process for Health Insurance Reimbursement Claims:

The general procedure to avail reimbursement claims for a health insurance policy is:

1. The first step is to go to the Insurance Help Desk at the hospital.
2. For identification, the ID card of the policy holder that has been given by the health insurance provider must be presented at the desk.
3. After verification by the hospital staff, a pre-authorization form will be submitted by them to the health insurance company of the insured person.
4. All the documents submitted are checked, authenticated and reviewed, before processing the claim as per the terms and conditions of the health insurance policy.
5. A health insurance company may also send their field doctor to ease the hospitalization process of the insured.
6. The claim is settled after all formalities are completed, as per the terms and conditions of the policy.