Health Insurance

A Simple Guide on Filing Claims in Health Insurance

By Admin
Mar 01, 2021
guide on filing claims in health insurance

During medical emergencies and other hospitalisation situations, a health insurance policy covers the incurred healthcare costs and gives financial assistance. 

But do you know how to file an error-free claim in your chosen health insurance plan? 

Health insurance claims are technical in nature. Though you might think that you have understood the benefits of the policy, most often than not, you might feel clueless when an actual claim is to be made. 

The health insurance claim process is, however, simple if you know the steps. So, here’s everything there is to know about making claims in health policies to have a smooth filing process during emergencies. 

Types of Health Insurance Claims-

There are two types of claim settlement processes – Cashless claims and Reimbursement claims. Let us find out what the two types are and their advantages and disadvantages. 

1. Cashless Claims
  • Under cashless claims, if you get admitted in a network hospital, the insurance provider settles the incurred medical bills directly with the hospital.
  • For example: If your incurred in-patient expense is INR 2 lakhs, then the insurance company would settle your medical bills up to  INR 2 lakhs with the hospital directly.
2. Reimbursement Claims
  • Under this claim settlement process, you will have to pay the incurred medical bills initially. Later on, after discharge from the hospital, the insurance company reimburses the medical costs incurred after you submit the claim form, the medical bills, and other required documents
  • For example: If your incurred healthcare cost was INR 2 lakhs, then you will have to pay the amount yourself and later get it reimbursed from the insurance company.

Pros and Cons of Cashless and Reimbursement claims- 

Types of Claim Pros Cons 
Cashless Claims 

Cashless claims are easier as the insurance provider takes care of all necessary medical expenses. . 

The paperwork  is not extensive and is sent to the insurance company by the hospital. This settlement process is, therefore, considerably hassle-free.

You cannot get hospitalised in just any hospital of your choice but only in networked hospitals as specified by the insurer. 

If the networked hospitals are not nearby, it would be difficult to opt for cashless claims in case of medical emergencies as you'd have to find one of the listed hospitals to get the treatment .

  

Reimbursement Claims You have the flexibility to choose whichever hospital you prefer to seek the best treatment for any medical condition. 

There might be an initial financial strain while having to shoulder the medical expenses. Reimbursement occurs only after the treatment is completed and the discharge summary is verified. 

This process can get cumbersome and time consuming with the documentation process as a lot of bills and reports are to be submitted to file the claim. 

How to process claims?

The claim filing and settlement process for both types of health insurance claims have been clearly explained below. 

Cashless Claims:

  • To avail cashless claims, it is mandatory for the insured to be treated in an empaneled hospital with an e-card /physical proof of the health insurance in the name of the insured.
  • Once hospitalised, all you have to do to initiate the claim settlement process is to provide the details of the health policy and health card to avail the cashless hospitalisation facility.
  • The claim process slightly varies depending on whether the treatment is planned or unplanned. Here’s how -
Planned Treatment Emergency Treatment 
1. Inform the insurance provider of the required treatment at least 3-4 days in advance.1. In such emergency scenarios, get admitted to an empanelled hospital. If you do not know of the hospitals networked with the insurance company, you can contact their helpdesk to enquire about the same.
2. Fill a pre-authorization form to avail cashless treatment feature and submit it to the company 3-4 days before hospitalization. A confirmation letter will be provided to you from the insurance company.2. Make sure to carry along the health card with you to avail the cashless treatment facility.
3. On the day of admission in the hospital, you will be asked to show your health insurance card (as provided along with every health insurance with the cashless treatment feature) and the confirmation letter.3. Fill up the pre-authorization form and send it across to the insurance provider within 24 hours of hospitalization. Then the insurer would issue an approval to approve cashless claims.
4. Once the claim request is validated, the insurance provider will settle the claim with the network hospital directly.4. The medical bills are then cleared directly by the insurance provider with the hospital.

5. The relevant medical bills are sent across to the insurance provider who then evaluates the incurred expenses in accordance with the policy coverage and settles the payments.

6. In case your claim gets rejected, an official letter from the insurance company will be sent to you stating the reasons for the same.

7. You can always contact the insurance company helpdesk for any further assistance if required.

Reimbursement Claims: 

  • If you choose a non-empaneled hospital, as per your choice, for a planned or unplanned healthcare treatment, then a reimbursement claim would occur.
  • In this case, you cannot use the cashless facility as the hospital is not in-network with the insurance company; therefore, you will have to pay for all the medical bills and other incurred costs before filing the claim.
  • Reimbursement claims can be initiated after you get discharged from the hospital. You will have to fill the reimbursement claim form and then provide the discharge summary, other relevant bills, documents, and reports to successfully file the claim. The discharge summary is a crucial document for this claim type.
  • The company will validate the claim under the policy cover and then will reimburse it to you.
  • In case of rejection of the claim, a letter with defined reasons will be provided.

 Documents Required for Filing a Claim-

The following documents are required to make claims under a health insurance plan: 

  1. Duly filled claim form - cashless claim form and reimbursement claim form according to the claim made
  2. Identity proof and policy document
  3. Medical Certificate or form as signed by the treating doctor.
  4. Authorized Prescription and cash memos from the pharmacy and hospital
  5. All medical bills in original
  6. Referral letter from the doctor advising hospitalization
  7. Discharge summary
  8. The investigation report and other reports in original
  9. In case of an accident, FIR or Medico-Legal Certificate is also required

Things to check before making a claim for a smoother process- 

1. Active Policy: 

  • It is important to make sure your policy is in force and has not lapsed. In case you haven’t renewed your health insurance after the policy term, your policy coverage will lapse thereby preventing your claim from getting processed.
  • So, make sure your health policies are active and all the premiums are timely paid.

2. Exclusions: 

  • Each health insurance comes with its set of exclusions. These are those healthcare treatments that are not covered by the policy. This means that the insurance provider is not liable to cover for the expenses incurred during these specific treatments, for example: cosmetic surgeries, self-inflicted injuries, etc.
  • If a claim is filed for any of the specified exclusion, it will not be approved by the insurance company. Make sure to go through the terms and conditions to account for all exclusions.

3. Sufficient Coverage: 

  • Coverage up to the sum insured is allowed under health insurance plans
  • It is, therefore, of greatest importance to make sure you’re sufficiently covered before filing a claim.

4. Group vs. Individual Health Insurance: 

  • In case you possess a group health plan and an individual health plan, it is advisable to exhaust the cover provided by the group health policy before claiming under the individual health insurance, if required.
  • This will keep your no-claim bonus in the individual health insurance plan intact.

 5. Health card for Cashless claim:

  • As mentioned, a health card is a must for cashless claims.
  • Make sure to keep it handy.

6. Claim Helpline Number:

  • The claim helpline number of the insurer is important; it will come in use for clarification on any claim related query

7. Networked Hospitals:

  • The networked hospital in your area must be noted down for emergencies.
  • It is advisable to avail  health insurance that provides a good choice of networked hospitals around your area.

Summary- 

Understand the health insurance claim process before making a claim so that your claim is settled without any hiccups.

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