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Insurance Article

Health Insurance: Claim Process Simplified

August 01 2016
Health Insurance - Claim Process

Simple steps to help you file a claim under your health insurance policy

So you’ve opted for a 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 you are not worrying in case of an emergency.

Opposed to common belief, making a claim is relatively easy. Let’s get acquainted with the various elements of the claim procedure to avoid unpleasant surprises in your time of need:

Claim Type

Claims are commonly of two types:

Cashless Claims Reimbursement Claims
Cashless claims can be made at a network hospital only. Reimbursement claims can be filed for treatment in a non-network or a network hospital.
Once your claim is approved, the amount will be paid directly to the hospital without your further involvement. Post-hospitalisation, you have to pay for all the expenses immediately and file for reimbursement later.

Claim Intimation

Claim intimation is a crucial step of the claim process as it informs the insurer of the upcoming expenses. There is a high possibility of your claim being denied if you fail to inform within the specified time as mentioned in your policy.

In 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 company within 24 hours.

Claim Forms

Pre-authorisation forms encapsulate all the information required to make a cashless claim. You have to submit a copy of required documents such as cashless ID, photo ID, previous consultation documents, if any for the company to approve the expenses. These documents will be verified by the hospital or a Third Party Administrator (TPA) to check if the illness or ailment is covered under the benefits of the policy.

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

Claim Investigation

Claim investigation helps the insurance companies analyse and differentiate fraudulent claims from the 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.

Claim Status

Your claim can be:

  • Accepted – In case your claim is accepted, the insurance company will send you the settlement letter mentioning the disbursed amount and the reasons along with the cheque.
  • Rejected – A rejection letter will be sent by the company, with the details of the rejection grounds as per terms and conditions of the policy. A rejected claim can be disputed by the proposer of the policy.
  • Queried – In case additional documents to back your claim are needed, the company will send you a query letter with the list of documents required. Failure to provide these within a given duration can lead to closure of the claim. Claim closure is, however, not claim rejection and can be reopened upon submission of necessary documents.

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