Documents Required for Health Insurance Claim

A hospital admission is the worst time to find out you are missing a document. You are already worried about the person on the bed. The last thing you want is a TPA desk asking for a paper you do not have, or a claim getting stuck weeks later because one bill went missing.

The fix is simple. Almost every health insurance claim in India runs on the same short list of documents. Once you know what that list is, and which documents matter for which type of claim, the whole process gets a lot less scary.

This guide walks you through exactly that. The documents you need when you buy a health insurance policy. The documents you need when you file a cashless claim. And the documents you need when you file a reimbursement claim.

Also, Read: Difference Between Life Insurance and Health Insurance

Documents Required for Buying Health Insurance

Being prepared for medical emergencies is crucial at any stage of your life. Even with a healthy lifestyle, no one is immune to medical issues. Having health insurance is important, considering the increasing risk of being vulnerable to medical issues due to various factors.

Once you have decided to invest in a health insurance plan, the next step is to consider a health insurance policy that complies with your age, income, and medical conditions. After selecting your health insurance plan, your insurance company will request for necessary documents.

Submission of required health insurance documents is important when buying a health insurance policy. To assist you in this process, here’s a list of documents required while buying a suitable health insurance plan.

1. Proof of Age

Among the list of documents required for buying a health insurance policy in India, proof of agе stands as the first and foremost document required to be submitted to your healthcare provider. Below is the list of documents that you can provide as proof of age:

• Aadhar Card
• Birth Certificate
• 10th or 12th Marksheet
• Voter’s ID card
• Passport
• Driving License
• PAN Card

2. Proof of Address

You are also required to submit an address proof. You can submit any of the following documents:

• Aadhar Card
• Voter’s ID card
• Passport
• Driver’s License
• Telephone bill or electricity bill
• Ration card

3. Identity Proof

At the time of buying insurance, it’s important to submit identity proof to the insurer to maintain records. To enjoy the benefits of a health insurance plan, you should first verify your identity by providing any of the below-mentioned ID proofs:

• Aadhar Card
• Voter’s ID card
• Passport
• Driving License
• Pan Card

4. Photographs

It is a must for you to submit passport-size photographs in line with the insurance company’s requirements.

5. Medical Reports

It’s important to undеrgo a mеdical еxamination before buying a health insurancе policy to help the insurer understand if you have any pre-existing diseases. You can also submit your tеst rеports when thе insurancе company asks for thе results of a prе-mеdical chеckup for better transparency.

Documents Required for Filing a Health Insurance Claim

To attain the maximum coverage of benefits while filing a claim, you must keep all the relevant and original documents with you to ensure a seamless claims process.

There are two ways of filing a health insurance claim:

1. Cashless insurance claim
2. Reimbursement insurance claim

Documents Required for Cashless Claims Process in Network Hospitals

A cashless claim means your insurer settles the hospital bill directly and you don’t pay upfront for anything covered by your policy. Earlier, this was only available at network hospitals empanelled with your insurer. Since January 2024, under the Cashless Everywhere initiative, you can request cashless treatment at almost any hospital in India, network or not. For planned procedures, you need to intimate your insurer at least 48 hours in advance; for emergencies, within 24 hours of admission. Once intimated, simply show your health card (physical or e-card) at the hospital’s TPA desk. 

List of Documents Required for a Cashless Claim in India

You are required to submit the below documents to the hospital’s third-party administrator:

• Duly filled form: You are advised to complete a specific claim form provided by the insurance company or the third-party administrator. The form will ask you to fill in your details and information regarding your medical condition.

• Health card (Physical or E-card): You must submit the cashless claim card, provided by the insurance company, to avail of cashless treatment at a network hospital.

• Government ID with photograph (e.g. Aadhaar card): You are required to submit the government ID proof with photographs, preferably an Aadhaar card, which may help prevent fraudulent activity and ensure a smooth claims process.

• Medical reports or consultation papers: Submit your pre-hospitalisation consultation, prescription, and test reports to provide details about the diagnosis and treatment plan. The basis of which the further treatment and plan of action is decided by the doctors and is further shared with the TPA or insurance company for the initial or pre-authorisation approval.

• Hospital bills: All the bills issued by the hospital, including any pharmacy bill, must be submitted to provide a detailed breakdown of charges.

• FIR (required in case of an accident): If thе hospitalisation is rеlatеd to any accidеnt, thеn thе policyholdеr is advised to submit an FIR, which serves as a legal document that supports thе accidеnt.

• All payment receipts and invoices: Any paymеnt or invoicе rеlatеd to thе trеatmеnt or hospitalisation should bе submittеd along with thе othеr documents at the TPA desk or insurance company to process further for cashless.

• Discharge summary: The dischargе summary should also be submitted to the third-party administrator, providing a comprehensive treatment overview.

Related Read: Difference Between Network and Non-network Hospital

Documents Required for Reimbursement Claims 

A reimbursement claim is when you pay the hospital bill yourself and then claim the amount back from your insurer. You’d typically go this route if cashless wasn’t activated in time; for instance, in an emergency where the hospital insisted on payment, or if the hospital declined to process cashless. Most insurers require you to submit reimbursement documents within 30 days of discharge, so don’t sit on the paperwork.

List of Documents Required for a Reimbursement Claim in India

• Filled and signed claim form: For a reimbursement claim, you should submit a dully filed and signed claim form to their insurance company or advisor.

• Hospital bill with payment receipts: Along with the above form, you must also submit every relevant document related to the treatment, hospitalisation bills, pharmacy bills, and other payments incurred at the hospital.

• Discharge summary: The discharge summary gives an overarching view of the medical condition and other important aspects of your treatment.

• Pre-hospitalisation and post-hospitalisation reports: Submitting your medical reports of pre and post-hospitalisation is very important during the reimbursement process to verify the treatment/procedure as advised by the doctors.

• Photo ID proof: Submit a government proof of identity with a photograph, which can be your PAN or Aadhaar card.

• FIR (Only in case of an accident): If thе trеatmеnt is rеlatеd to any accidеnt, thеn thе policyholdеr is advisеd to submit an FIR, which sеrvеs as a lеgal documеnt that supports thе accidеnt.

Also, Read: Maternity Health Insurance

Why Choose Onsurity as Your Health Insurance Provider?

Onsurity is one of India’s leading insurtech companies, offering health and wellness plans for businesses of every size. From teams as small as three  to large enterprises, we build coverage that actually fits the way your company works, with a strong claim settlement track record that makes sure your people are looked after when it matters most.

• Comprehensive healthcare plans are competitively priced, making them affordable for businesses of all sizes.

• We provide free doctor teleconsultations, making it easier and more convenient for members to receive healthcare assistance at the click of a button.

• We offer discounts on preventive health check-ups to help employees stay healthy and detect health concerns early on.

•  Employees can extend their plan to spouses, children, parents,  in-laws, and even siblings, all under a single policy.

• We have a dedicated claims concierge that is driven by qualified doctors to help manage claims end-to-end in a hassle-free manner.

• Onsurity offers a variety of wellness benefits including dental treatment, physical fitness perks, and mental health benefits, among many others to ensure overall well-being.

Documents Required for Group Health Insurance Claim

Documents play a very crucial role when applying for a health insurance claim. The list of documents required to get a claim on a group health insurance policy are listed below:

• Duly filled and signed the original claim form: The group health insurance claim consists of 2 parts, part A and Part B. Part A is to be filled and signed by the employee whereas Part B should be filled and signed by the hospital.

• Hospitalisation bills: It is mandatory to submit all original bills or invoices from the pharmacy or any other bills generated by the hospital.

• Medical reports: Submit all pathological reports followed by diagnostic tests, doctor’s consultation, or any other medical report.

• Final payment invoice: The employee must submit the final invoice generated by the hospital, including the breakdown of the specific medical expenses incurred. (consultation fees, medical procedure fees, fees of tools or machines used, fees for generating diagnosis reports, etc.)

• Health card: The policy holder is advised to carry their original health card it can be in a physical form or an E-card.

Other important documents the employee must submit are:

• Photocopy of Government ID proof with a photograph
• Date of admission and discharge

Suggested Read: What is a Group Health Insurance Policy?

How Do You File a Health Insurance Claim with the Required Documents?

When the time arises for you to use your health insurance policy, it is best to learn about the claim process beforehand. But if you know the claim process, you can have a seamless experience during your health insurance claim.

A health insurance claim is when you request your insurance company to provide you with financial assets according to your policy coverage, which is mentioned in your health insurance policy document.

We have brought you the step-by-step process to help you file a health insurance claim hassle-free. But before moving forward, you should understand the types of health insurance claims.

1. Step-by-step Procedure for Filing a Cashless Claim

You can get a cashless claim when treated for a medical issue in-network hospital. Simply put, your health insurance company will pay for the cost incurred at the hospital. The policy holder has to pay for only those charges at the hospital that are not covered in the insurance policy.

• Fill out the claim form: To get a cashless claim, you must first fill out the pre-authorisation form and submit it at the third-party administration counter when admitting the patient or policyholder.

• Submit your relevant documents: Any relevant documentation must be turned in at the Third-Party Administration counter. This might involve the cashless medical services your insurance covers. Additionally, copies of specific KYC papers will be kept for verification reasons.

• Claim successful: After the hospital verifies your documents, your insurance company approves your hospitalisation for their cashless claim. You should always ask for a copy of documents concerning the treatment and stay.

Following the guidelines mentioned above will help you settle the cashless health insurance claim smoothly. Ensure that all your medical reports, medical tests, and discharge bills are with you for future reference.

2. Step-by-step Procedure for Filing a Reimbursement Claim

To get an insurance claim, you are advised to submit all the below mentioned documents to the insurer.

• Claim Form
• Medical Certificates
• Diagnosis Reports
• ID Proof
• Discharge Card
• Health Card
• Discharge Summary
• Prescriptions and other medical bills
• FIR (applicable only if it is a case of accident)

Fulfilling the claim within 30 days of your discharge is advisable. Failing to do so might develop chances of claim rejection.

Conclusion

Most health insurance claims do not get rejected because of the illness. They get rejected because a document was missing, late, or did not match what the hospital sent across. That is a fixable problem.

The simplest fix is to keep one folder on your phone or laptop with your policy document, health card, ID proof, address proof, and every medical report from your treatment. Name the files clearly so you can find them in a hurry. This one habit prevents most of the back and forth that drags a claim out for weeks.

The second fix is knowing which type of claim you are filing. If it is cashless, tell your insurer before you get admitted, or as soon as possible after an emergency, and let the hospital handle the rest. If it is reimbursement, you pay the hospital first and then send all the bills, reports, and the signed claim form to your insurer within 30 days of discharge. Mixing these up, or waiting too long, is what causes most of the trouble.

If your cover comes through your employer, the work gets even lighter. At Onsurity, our Good Doctors team, a team of qualified doctors, helps you with query resolution and end to end claim assistance, so you are never left figuring things out alone.

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