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    Health Insurance Claims

    A health insurance plan comes into effect when the insured is hospitalised or when the insured faces a medical contingency and incurs cost. At that time, if the hospitalisation or the medical expenses are covered by the health insurance plan, a health insurance claim is said to occur. Under a health insurance claim, the insurance company pays the medical expenses which incur in case of any medical contingency.


    Types of health insurance claims

    There are two types of claims admissible in a health insurance policy. These are as follows:


    • Cashless
    • Reimbursement

    Let’s understand the meaning and the processes involved in both these types of claims.


    Cashless claims

    Cashless settlement of health insurance claims occurs when the insured seeks treatment in a networked hospital. A networked hospital is one which is tied-up with the insurance company. Since treatments are taken at a networked hospital, the insurance company settles the hospital bills directly with the hospital. You, therefore, do not have to take the burden of paying for the medical expenses yourself.

    Here are the steps involved in availing a cashless claim settlement


    • If you are seeking a planned treatment, inform the insurance company beforehand. Intimation should be given at least 3 to 4 days prior to being hospitalised. A pre-authorisation form needs to be filled in and submitted with the insurance company. This form acts as a claim notification. In case of planned hospitalisation, the form should be filled in and submitted 3 to 4 days in advance.
    • If there is a medical emergency and the insured is being hospitalised under an emergency situation, the insurance company should be informed and the pre-authorisation form should be submitted within 24 hours of hospitalisation.
    • Once the pre-authorisation form is submitted, the insurance company assesses the claim based on the form and allows cashless claim settlements.
    • The insured can then avail the required treatments without paying the medical bills incurred.
    • All medical bills, medical reports and other medical documents should be submitted to the insurance company.
    • If there are other expenses which are being covered, original documented proofs of such expenses should also be submitted with the insurance company.

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    How Does Health Insurance Claim Process Work?

    Your insurance provider offers either a Reimbursement Process or a Cashless Claim Process. But how do you approach these processes if you are not aware of how do they work?

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    The Discharge Summary and the original medical bills are necessary for getting the medical expenses reimbursed under a reimbursement claim.

    A TPA is a Third Party Administrator which facilitates claim settlement between the insurance company and the insured. TPAs are available at the hospital reception desks. They form the point of contact for the customer through which the customer can intimate the claim to the insurance company.

    Many insurance companies allow in-house claim settlement. Under this, there is no TPA. The insurance company handles the claims internally. This allows speedy claim settlements.

    In case of claim rejection, the insured should find the reason of rejection. If it is a justified reason, the claim would not be paid. However, if the insured believes that the claim is admissible, a complaint can be lodged with the insurance company’s grievance redressal cell.

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