Simple Steps to File a Health Insurance Claim

So you’ve opted for health insurance to safeguard your finances against the soaring healthcare costs. Now that you have this assurance, it is important to understand how the claim process works to ensure smooth proceedings during an emergency.

 Opposed to common belief, the health insurance claim process is relatively easy. By understanding this, you can simplify claim filing and ensure timely settlements. Whether you are going for a cashless facility or reimbursement, this blog is your guide to all the steps to a successful health insurance claim.

How to Make a Health Insurance Claim?

To make a successful insurance claim, you should be familiar with the policy's terms, inclusions, exclusions, and limits. Follow these steps to initiate a claim-

1. Inform your insurance provider about the medical treatment or hospitalisation immediately.
2. Check the health insurance plan paper and collect all required documents for filing a claim.
3. Submit the claim following the guidelines provided by your insurer.
4. Keep track of the claim process through the online portal or customer service of the insurance provider.

Types of Health Insurance Claims 

Health insurance claims can be divided into two types- cashless and reimbursement claims. Both have unique processes and specific documentation requirements.

Cashless Claims

Cashless claims can be made at a network hospital only. Once your claim is approved, the amount will be paid directly to the hospital without your further involvement.

Reimbursement Claims

Reimbursement claims can be filed for treatment in a non-network or a network hospital. Post-hospitalisation, you have to pay for all the expenses immediately and file for reimbursement later.

Step-by-Step Procedure for Filing a Cashless Health Insurance Claim

Follow these steps if you are opting for a cashless insurance claim:

1. Choose a network hospital of the insurance provider for getting treatment.
2. Inform the insurer about the planned or emergency hospitalisation.
3. Submit the pre-authorisation form at the hospital.
4. Get the pre-authorisation approved by the insurer.
5. The insurance provider will take care of the bills.

Step-by-Step Procedure for Filing a Reimbursement Claim

For reimbursement claims, no pre-authorisation form is generally needed. However, after discharge, you need to submit all the documents on the out-of-pocket expenses. You can mail these documents along with the duly filled claim form to your service provider or TPA.

1. Notify the insurer about the hospitalisation
2. Pay the medical bills upfront
3. Collect the hospital bills, medicine prescriptions, and test reports
4. Fill out the claim form, attach the required documents, and submit.
5. Await the review and processing of the claim by the insurer.

Types of Hospitalisations Covered by Health Insurance Claims

The most common types of hospitalisations covered by medical insurance providers are-

1. Planned Hospitalisation: For elective surgeries or treatments scheduled in advance
2. Emergency Hospitalisation: Unplanned medical situations that require immediate attention
3. Day-care Treatment: Medical procedure that does not need 24-hour hospitalisation
4. Domiciliary Hospitalisation: Treatments done at home due to the inability to transfer the patient to a medical unit

In the case of planned hospitalisation at a network hospital, the specified time required to intimate your insurance company is at least 1-2 days in advance. For emergency hospitalisation, you have to inform the insurer within 24 hours.

Documents Needed to File a Health Insurance Claim

Before filling out a health insurance claim, make sure to have the following documents ready-

1. Completed claim form 
2. Original hospital bills with a breakdown of the cost
3. A summary of hospitalisation and treatments or discharge summary
4. Prescription, test reports, and diagnostic results
5. Identity proof of the policyholder or patient
6. Bank details in case of reimbursement claims

Things to Consider While Applying for a Health Insurance Claim

There are certain points that you need to know before applying for a health insurance claim-

1. Waiting Period: Ensure the policy covers the health condition without any waiting period restrictions.
2. Deadlines: All claims must be submitted on time to ensure smooth processing.
3. Network Hospitals: Check the hospitals on the insurance provider’s network to benefit from a cashless claim facility. 
4. Pre-existing Conditions: See if the insurance claim covers pre-existing health conditions.

Tips to Avoid Health Insurance Claim Rejections

Notifying the insurer on time, providing correct information, and submitting completed documents are some of the important steps to avoid claim rejections.

Make sure to-

• Disclose accurate personal and medical details while buying the policy
• Adhere to the terms of the policy
• Submit all required documents with claim form
• Inform the policy provider on time about hospitalisation
• Review all forms and fills before submitting

Steps to Check the Status of a Health Insurance Claim

You can check the status of your health insurance claim in the following ways-

Website

1. Go to the online portal of the insurance provider.
2. Give your login credentials and the claim reference number to get the status.

Customer care service

1. Call the customer care department of the insurance provider
2. As requested, provide your claim reference number and other details to know the claim status.

Mobile app

1. Download the mobile application of the insurer
2. Login with your details
3. Enter your policy number and get the status of your claim.

Email updates

 Check your inbox for any status updates sent from the insurance provider.

FAQS

1. What is the difference between cashless and reimbursement claims?

Cashless claims are direct settlements between the insurance provider and the hospital, while reimbursement claims include the policyholder, who the insurer repays after the hospital bills have been paid upfront.

2. Can I file a claim for pre-existing conditions?

You can file a claim for pre-existing conditions after the waiting period as specified by the policy.

3. When does a claim get rejected?

A claim can be rejected due to non-disclosure of important information, delay in claim filing, or in case the medical condition is beyond the coverage provided by the policy. Always provide correct details and adhere to important deadlines to avoid a claim rejection.

4. What happens if a claim is rejected?

In case of a claim rejection, you can contact the insurance provider with additional documents or clarification and follow their guidelines to clear the issue.

5. Can I file multiple claims in a year?

Yes, if the total claim amount is under the sum insured by the policy, you can file for more than one claim in a year.

6. Can I make a yearly claim for insurance?

Yes, you can make a yearly claim on your health insurance within the limit allowed by the policy.

7. What is a claim investigation?

Claim investigation helps insurance companies analyse and differentiate fraudulent claims from genuine ones. Your claim form and documents will be thoroughly scrutinised and a suitable decision will be made. Therefore, ensure you fill in the details correctly in the form and submit the documents as per the requirement.

Conclusion

Having a health insurance plan is not enough, timely filing of claims during an emergency is essential to gain complete benefit of the policy. The claim process is simple to ensure the policyholder gets the required financial support during a health crisis. However, it is essential to be familiar with the steps of filing a claim and the necessary documents required to ensure the procedure is hassle-free.

Disclaimer: The information provided in this blog is for educational and informational purposes only. It is not intended as a substitute for professional advice, diagnosis or treatment. Please consult a certified medical and/or nutrition professional for any questions. Relying on any information provided in this blog is solely at your own risk, and ICICI Lombard is not responsible for any effects or consequences resulting from the use of the information shared.