Health Insurance Claim Process in India

Health insurance provides a financial bailout against sudden health costs. Yet merely holding a health policy is insufficient — it is imperative to comprehend the claim process so that assistance arrives promptly at the moment you need it most. This is a guide that decodes the kinds, procedures, and suggestions to manage the health insurance claims procedure in India.

What does a Health Insurance Claim mean?

Health insurance claim refers to a written request of an insured person on an insurance company to pay the cost of treatment as stipulated by the policy. Either it can be processed on a cashless basis—with the insurer covering the hospital directly—or through reimbursement, in which you pay first and then receive reimbursement from the insurer.

You will be surprised to learn:
In 2020, the penetration of health insurance in India was still low at 37 percent, which means that there is an increasing awareness.

Types of Health Insurance Claims

How to File a Claim on Health Insurance in India: Step-by-Step

1. Know Your Policy
   Familiarise yourself with your policy’s inclusions and exclusions, the coverage limits, the waiting periods, and the hospitals in its network.

2. Define the Type of Claim to be Submitted

   • Cashless: Available only at network hospitals.
   • Reimbursement: Eligible at any hospital, either inside or outside the network.

3. Notice the Insurer

   • For planned hospitalization, inform the insurer beforehand.
   • In case of emergency, inform the insurer within 24 hours of admission.

4. Provide the Requisite Documents
   Include:

   • Completely filled claim form
   • Hospital bills
   • Discharge summary
   • Prescriptions and diagnostic reports
   • ID proof and copy of the policy

5. Review and Processing
   The insurer checks and verifies the documents. In general, cashless claims move through the processing stage more swiftly than reimbursement claims.

6. Either Approval or Rejection
   Once approved, the insurer settles the bills cashless or reimburses.
   If the claim is declined, you can submit supplementary documents for an appeal.

Documents Needed for Filing Health Insurance Claims

Pro Tip: Be sure to make photocopies and scan all documents before their submission.

Cashless Claim Process – An Overview

1. Select a hospital on the network list.
2. Complete the pre-authorization form and hand it in at the insurance desk.
3. Insurer examines the claim and gives its approval.
4. Get treated. Pay out of pocket solely for the treatments not covered by the policy.
5. Hospital forwards the final bill to the insurer.

Cashless vs Reimbursement at a Glance

Process for Reimbursement

1. Seek medical care in any hospital.
2. Gather all original documents.
3. Complete the claim form.
4. Forward the expenses package to the insurer.
5. The insurer examines the claim and sends reimbursement once it is approved.

Frequent Causes of Claim Rejection

• Documentation that is either incomplete or incorrect
• Exclusion of policy (e.g. cosmetic surgery, breach of the waiting period)
• Failure to disclose existing pre-condition
• For cashless cases, the hospital is not within the insurer’s network
• Late submission of claim notice

Expert Insight:
“Keeping clear of any claim snags requires knowledge of your policy and proactively reaching out to your insurer.”
— Dr. Anil Mehta, Insurance Consultant

Hurdles during the Claim Process

• Deficit in communication among the policyholder, hospital, and insurer
• Ignorance of policy exclusions
• Inability to check status of hospital network
• Poor documentation specifications

Things to Do to Prevent Claim Rejection

• Study your policy carefully
• Make sure to opt for network hospitals whenever pursuing a cashless claim
• Disclose every pre-existing condition
• Maintain all bills and prescriptions
• Inform insurer early enough

Did you know?
In India, close to 15% of claims are denied on account of inadequate documentation or concealed pre-existing conditions.

Processing Time for Claims

Elements that Impact Timing

• Nature of the claim
• Document completeness
• Efficiency of insurer’s in-house claim processing

Advantages of Comprehending the Claim Process

• Quicker Settlements: Smooth and highly efficient settlements
• Cost Saving: A reduced likelihood of having to pay out of pocket
• Informed Decision Making: Choices of hospitals, treatment, and add-ons that are more informed

Pro Tip: Look at your policy once a year and make sure you keep up with the updates.

FAQs

Q1: If my claim is turned down, what steps should I take?
A: Examine the cause of the rejection, supply supplemental information when necessary, and lodge an appeal with the insurer. Should you still be dissatisfied, contact the insurance ombudsman.

Q2: Are outpatient (OPD) treatments eligible for claim reimbursement?
A: In most cases, OPD costs are not reimbursed unless you have specifically purchased the OPD add-on benefit.

Q3: What is the maximum number of claims I can submit in the year?
A: Most policies permit unlimited claims provided the sum insured has yet to be exhausted.

Q4: Are pre-existing conditions included?
A: Yes, however, you must wait for periods of 2–4 years, as specified by the policy.

Q5: What does a No-Claim Bonus (NCB) refer to?
A: NCB stands as a reward for avoiding any claim substitutions in a single policy year. It enhances your sum insured or cuts down on your renewal premium.

Q6: May I resubmit the claim after it has been rejected?
A: Yes, you may re-submit your claim after rectifying the pertinent errors or furnishing any missing documents.

Q7: What is the function of a TPA?
A: The Third-Party Administrator facilitates the claim-processing activities between the insurer and the hospital.

Conclusion

To make the best out of your health policy during medical emergencies, it is important to be able to understand the health insurance claim process. Keeping your awareness of the procedures, requisite paperwork, and communication procedures will help prevent avoidable delays and claim rejections. Arming yourself with knowledge and readiness allows you to sail through the process with greater ease and less stress.

Stay informed. Stay insured. Stay stress-free.