Health Insurance Claim Process: A Comprehensive Guide

Health Insurance Claim

In India, where healthcare costs can surge unexpectedly, having health insurance is a crucial lifeline. For those new to health insurance, navigating the process of filing a claim may feel like entering uncharted territory. Understanding this process is not just a formality; it’s key to maximising your healthcare plan’s benefits.

According to data from IRDAI, as of March 31, 2023, approximately 86% of the total registered number of claims were settled by insurers, while 8% were repudiated, and the remaining 6% were pending settlement. The average amount disbursed per claim stood at Rs 30,087.

When it comes to settling claims, 75% were processed through third-party administrators (TPAs), with the remaining 25% managed through in-house mechanisms. In terms of settlement modes, 56% of claims were settled through cashless transactions, 42% via reimbursement, and a small 2% through a combination of both methods.

These statistics underscore the pivotal role health insurance plays in managing healthcare expenses or medical bills.

Knowing the ins and outs of the claim process is critical to ensuring that you’re able to make the most of your health insurance policy. In this article, we’ll throw light on the details of the health insurance claims process.

Also, Read: Difference Between Life Insurance and Health Insurance

What is a Health Insurance Claim?

A health insurance claim is simply a formal way of asking your health insurance company to cover or reimburse you for the medical expenses you’ve incurred either for planned hospitalisation or emergency hospitalisation.

How Does Health Insurance Claim Work?

You, as the policyholder, get to choose between two distinct options – cashless claim and reimbursement claim, each with its own unique process.

Example 1:

Imagine you’re scheduled for a planned hospitalisation at your chosen hospital. You inform your insurer by presenting your health card at the TPA desk, which contains a policy number enabling them to verify your health policy details.

This process also facilitates the initial approval of the claim amount based on the treatment you require. Essentially, this means you can go to the hospital, get admitted, receive treatment, and be discharged instantly without having to make any payments upfront.

Example 2:

You had an unexpected medical expense and needed immediate attention. You choose a hospital outside your insurer’s network. You pay the bills yourself, keep the bill receipts safely, and then submit them to your insurer. Once they verify everything, you receive the agreed-upon reimbursement. or emergency hospitalisation.

Also, Read: Types of Health Insurance

Types of Health Insurance Claims

Imagine a scenario where you receive medical treatment without the burden of upfront payments. That’s the promise of cashless claims. This process unfolds in two main scenarios:

1. Cashless claim for planned hospitalisation

Generally, it’s advisable to contact at least 72 hours before your scheduled admission. It’s a pre-approval step, ensuring that when the time comes, you can focus solely on your health, without worrying about the financial bills.

Submit a pre-authorisation form along with your doctor’s advice and any other relevant documents requested by your insurer and have a stress-free experience.

2. Cashless claim for emergency hospitalisation

In case of unplanned hospitalisation, immediately inform your insurance company. This step ensures that they are aware of the situation and can expedite the process, facilitating quick access to medical care.

Get admitted, and the hospital notifies the insurance company. Once you’re admitted to the hospital, the TPA takes over the takes. They notify your insurance company about the emergency admission, kickstarting the cashless claim process. It’s like having a safety net in place for unexpected healthcare needs.

Quick Read: Cashless Health Insurance Claims

3. Reimbursement claim: Navigating post-treatment costs 

For scenarios where cashless facilities aren’t available or opted for, the reimbursement claim process unfolds:

Step 1: Pay and Retain Receipts:

In situations where cashless facilities are unavailable or you opt for reimbursement, you become the initial payer. Think of it as settling the bill upfront. It’s crucial to keep a record of every expense – retain all original bills, relevant documents, and receipts as proof of your medical expenditure.

Step 2: Claim Submission:

Submit the reimbursement claim form along with supporting documents to the insurance company, essentially, providing evidence of your medical expenses. This detailed submission sets the stage for a thorough review.

Step 3: Claim Verification:

Once your claim is submitted, it goes through a meticulous verification process. The insurer examines each document to ensure accuracy and adherence to policy terms. Think of this as a quality check ensuring that every penny you spent on medical expenses is accounted for. Upon successful verification, the insurer disburses the eligible reimbursement amount.

Understanding these nuances helps you navigate the health insurance industry with confidence, whether you opt for a cashless claim for planned or emergency hospitalisation, or embark on the reimbursement journey after settling the bills yourself.

Also, Read: Group Health Insurance for Employees

Step by Step in the process for filing a Health Insurance claim 

1. Cashless Health Insurance Claim Process

Step 1: Hospital Network Selection:

Choose a hospital within the insurer’s network for a seamless experience. Opting for a hospital within this network ensures a smooth, cashless experience. These hospitals have existing tie-ups with the insurer, simplifying the billing process and ensuring standardised pricing.

Step 2: Pre-Authorisation Request:

Submit the pre-authorisation form and required documents. This proactive step ensures that your insurer is aware of the upcoming medical treatment, streamlining the process for both you and the hospital.

Step 3: Incoming approval:

After submitting your pre-authorisation request, please wait for the initial approval. Your insurer reviews the documents and approves the treatment plan. Once approved, you can proceed with your treatment worry-free.

a) Cashless Claim Process for Planned Hospitalisation

Step 1: Notify the insurer about the planned hospitalisation well in advance

When planning a hospital visit, notify your insurer well in advance about the hospitalisation. This timely notification allows them to prepare for your claim, making the process more efficient.

Step 2: Seek pre-approval for planned treatments to streamline the process

This step not only streamlines the administrative process but also provides clarity on the coverage for specific treatments.

Step 3: Submit all necessary documents post-hospitalisation for a smooth claim process

This includes medical certificates, bills, prescriptions, diagnostic tests, discharge summary and any other required paperwork.

Also, Read: Simplifying the Claims Process for Your Employees

b) Claim Process for Emergency Hospitalisation

Step 1: Notify the insurer about the planned hospitalisation well in advance

When planning a hospital visit, notify your insurer well in advance about the hospitalisation. This timely notification allows them to prepare for your claim, making the process more efficient.

Step 2: Seek pre-approval for planned treatments to streamline the process

This step not only streamlines the administrative process but also provides clarity on the coverage for specific treatments.

Step 3: Submit all necessary documents post-hospitalisation for a smooth claim process

This includes medical certificates, bills, prescriptions, diagnostic tests, discharge summary and any other required paperwork.

2. Reimbursement Claim Process

Step 1: Settle initial medical expenses and diligently retain all bills

When cashless facilities aren’t available or you choose reimbursement, you become the initial payer. Settle the initial medical expenses yourself and meticulously retain all bills. These documents serve as the foundation for your reimbursement claim.

Step 2: Submit the reimbursement claim form with supporting and relevant documents

Fill out the reimbursement claim form provided by your insurer and gather all supporting documents – essentially creating a dossier of evidence for your medical expenses.

Step 3: The insurer reviews the claim and disburses the eligible amount

Once your claim is submitted, it undergoes a thorough review. The insurer examines each document to ensure accuracy and adherence to health policy terms and provide the investigation reports. This is the final quality check before your insurer disburses the eligible reimbursement amount. It’s the culmination of your efforts, ensuring that every penny you spend on medical expenses is accounted for.

Understanding these detailed steps empowers you to navigate the health insurance claim process with precision, ensuring a seamless experience tailored to your specific needs.

Related Read: Documents Required for Health Insurance

Relevant Documents Required for Health Insurance Claim Process   

1. Duly Filled Claim Form

What it is:

This is like the starting point of your claim journey. The claim form is a document provided by your insurer that you need to fill out. It captures essential details about your medical treatment, ensuring your insurer has all the necessary information to process your claim.

Why it’s important:

Remember the more accurate and complete the information, the smoother your claim process will be.

2. Original Hospital Bills and Receipts

What they are:

Every bill you receive from the hospital and every receipt for the services you’ve received should be kept and submitted as part of your claim.

Why they’re important:

These documents validate the expenses you’ve incurred. They’re like your financial trail, showing exactly where your money went during your treatment.

3. Medical Certificates and Reports

What they are:

These are the official documents from your healthcare provider detailing your medical condition, diagnosis, and treatment plan.

Why they’re important:

Consider these as your medical evidence. They help the insurer understand the specifics of your health situation and the necessity of the treatments you’ve undergone.

4. Prescriptions and Pharmacy Bills

What they are:

Prescriptions are the doctor’s orders for your medication, and pharmacy bills are the receipts from where you bought your medicines.

Why they’re important:

These documents show what medications you were prescribed, and the costs associated. They contribute to the overall scenario of your medical expenses.

5. Discharge Summary

What it is:

The discharge summary is a document prepared by your treating doctor, summarising your entire hospital stay, including the treatment received and follow-up recommendations.

Why it’s important:

It provides a holistic view of your treatment, helping the insurer understand the complete story of your hospitalisation.

6. Photo ID and Health card

What they are:

Your photo ID could be your passport, driving license, or any other government-issued identification. A Health card is a digital card containing a policy number and policy holder details.

Why they’re important:

Your photo ID verifies your identity, and policy documents confirm your coverage. It is a fundamental document establishing your eligibility for a health insurance claim.

7. Any Other Supporting Documents Specified by the Insurer

What they are:

These could be additional documents requested by your insurer based on the specifics of your claim. It could include specialist consultation notes, test reports, or any other relevant paperwork.

Why they’re important:

If your insurer requests specific documents, providing them ensures your claim process is thorough and comprehensive.

Understanding and gathering these documents is like preparing yourself for a smoother claim process. The more organised and complete it is, the easier and faster your insurer can process your claim, ensuring you receive the support you need during your healthcare journey.

Also, Read: A Guide to Maternity Health Insurance

How To Check the Health Insurance Claim Status?

Before we dive into the methods of checking your health insurance claim status, let’s understand why monitoring its progress is crucial. Tracking your claim isn’t just a procedural step; it’s your window into the backend of your reimbursement or cashless process.

It helps you stay informed, anticipate potential issues, and ensures that your claim moves through the pipeline smoothly, avoiding unnecessary delays.

Is It Possible to Claim Health Insurance from Multiple Insurers?

Claiming health insurance benefits from multiple insurers, also known as “double-dipping,” is a possibility, though not a common scenario. This happens when an individual is covered under more than one health insurance policy, either through multiple individual policies or a combination of individual and group policies.

1. Coordination Between Insurers: While the concept might sound complex, the key to a smooth multiple insurer claims process lies in effective coordination between the insurers involved. Here’s how it works:

2. Primary and Secondary Insurers: When you have multiple health insurance policies, one policy becomes the primary insurer, and the others become secondary insurers.

The primary insurer is the first to pay the claim, and the secondary insurer covers the remaining expenses.

Example: You undergo a medical procedure costing ₹10,000, and you have two insurance policies. Policy A is your primary insurer, covering ₹6,000, and Policy B is your secondary insurer, covering the remaining ₹4,000.

3. Informing Both Insurers: It’s crucial to inform both insurers about the existence of other policies. This transparency helps in avoiding disputes and ensures a coordinated approach.

Example: You submit a claim to Policy A, and they cover their share. You then inform Policy B about the remaining expenses, and they process the secondary claim.

4. Policy Terms and Conditions: Each policy has its terms and conditions regarding the contribution clause. Understanding these terms is crucial for a seamless claims process.

Example: Policy A might cover outpatient expenses, while Policy B may have a higher coverage limit for inpatient care. Coordinating benefits ensure you maximise coverage under both policies.

5. Rahul has two health insurance policies: Policy X from his employer and Policy Y, which he purchased individually.

• John undergoes a surgery costing ₹50,000.
• Policy X (Primary): Covers ₹40,000.
• Policy Y (Secondary): Covers the remaining ₹10,000.

Related Read: What is Group Health Insurance Policy?

Multiple Insurance Claim Process

• Rahul informs both insurers about the medical procedure and submits the necessary documents.
• Policy X processes the claim first, covering its share.
• Rahul then informs Policy Y about the remaining expenses, and they process the secondary claim.

Contribution clause:

• Policy X covers inpatient expenses, while Policy Y provides additional coverage for post-operative care and medications.
• The coordination ensures John receives maximum coverage from both policies without exceeding the total medical expenses.

Tips for policyholders:

1. Policy review: Regularly review the terms and conditions of all your health insurance policies to understand coordination rules.
2. Transparent communication: Inform both insurers about the existence of multiple policies to facilitate smoother coordination.
3. Optimal utilisation: Understand the strengths of each policy and optimise their utilisation for maximum coverage.

While claiming health insurance benefits from multiple insurers may seem intricate, effective coordination and a clear understanding of policy terms can ensure you make the most of your coverage. It’s a scenario that might not arise frequently, but when it does, being informed and transparent can lead to a seamless claims process.

Also, Read: Why To Invest in Customised Healthcare Plans for Employees?

Common Challenges in Health Insurance Claim Process

• Policy Exclusions: Some policies have specific exclusions for certain treatments or pre-existing conditions.

• Incorrect Information: Inaccuracies in personal details or medical information.

• Waiting Periods: Attempting to claim for a condition during the waiting period when coverage is restricted.

• Non-disclosure: Failure to disclose pre-existing conditions during policy application.

• Submitting incomplete or inaccurate claim forms can lead to unnecessary delays.

Tips for a Smooth Health Insurance Claims Process to Avoid Rejections

Ensuring a seamless health insurance claims process involves more than just submitting documents; it’s about adopting best practices to mitigate the risk of rejections. Here’s a detailed breakdown of actionable tips:

1. Policy Scrutiny: Understand Your Coverage Inside Out

Policies can have nuances and specific terms. Scrutinising your policy thoroughly ensures you’re aware of its inclusions, exclusions, and any waiting periods.

• Read the policy document: Go through your policy document carefully, paying attention to details.

• Clarify doubts: If any terms are unclear, seek clarification from your insurer.

2. Timely Intimation: Initiate the Process Promptly

• Immediate notification: In case of planned hospitalisation or emergencies, notify your insurer as soon as possible.

• Provide essential details: Share all relevant information, such as the reason for hospitalisation and expected treatment.

3. Accurate Documentation: Precision is Key

• Create a checklist: List down all required documents for your specific claim.

• Double-check details: Ensure all information on forms and documents is accurate and matches the policy details.

4. Proactive Follow-Up: Stay in the Loop  

• Set follow-up reminders: Establish a schedule for checking your claim status.

• Utilise multiple channels: Combine online portals, emails, and direct calls to stay connected with your insurer.

5. Transparent Communication: Keep Your Insurer in the Loop  

• Inform about changes: If your health status changes during the claim process, update your insurer.

• Seek clarification: If you have doubts or concerns, communicate with your insurer promptly.

6. Understanding Policy Limits: Know Your Coverage Cap

• Review coverage limits: Know the maximum coverage for different aspects of your policy.

• Prioritise expenses: If you have multiple claims, prioritise based on coverage limits.

7. Seek Pre-Approval for Planned Procedures: Plan Ahead

• Contact your insurer early: Initiate pre-authorisation for planned treatments well in advance.

• Provide complete information: Ensure all necessary details are submitted during pre-authorisation.

By incorporating these detailed tips into your approach, you not only enhance the likelihood of a smooth health insurance claims process but also proactively contribute to a hassle-free experience. Remember, the key is meticulous preparation and staying informed throughout the entire claim journey.

Suggested Read: Difference Between Network and Non-network Hospital

Things To Consider While Applying for Health Insurance Claim Process

Before embarking on the health insurance claim journey, it’s essential to consider various factors to ensure a seamless and efficient process. Here’s a detailed breakdown of what to keep in mind:

• Policy network availability: Check the list of network hospitals in your policy documents.

• Proximity to your location: Choose network hospitals that are easily accessible to you.

• Waiting periods: Know the waiting periods for specific treatments.

• Coverage limits: Understand overall coverage limits and any sub-limits for specific treatments.

• Pre-existing conditions: Be aware of how pre-existing conditions are handled in your policy.

• Sub-limits for treatments: Know if there are specific sub-limits for surgeries, diagnostics, or other treatments.

• Policy renewal impact: Understand how claim limits reset during policy renewal.

• Initiate pre-authorisation early: Contact your insurer well in advance for planned treatments.

• Complete documentation: Ensure all necessary documents are submitted during the pre-authorisation process.

• Inform about changes: If your health condition changes during the claim process, update your insurer.

• Clarify doubts: Seek clarification from your insurer about any unclear policy terms.

By carefully considering these factors before applying for a health insurance claim, you set the stage for a more informed and successful journey through the claim process. Remember, a proactive and informed approach ensures that your health insurance works for you when you need it the most.

Also, Read: Group Health Insurance Claim Tips

Conclusion

The health insurance claim process is not merely a hurdle; it’s an integral part of safeguarding your well-being. By understanding the steps involved, you gain the confidence and control to navigate the healthcare system effectively.

Remember, knowledge is your superpower: it empowers you to advocate for yourself, make informed decisions, and ensure your health insurance works for you. Let Onsurity be your trusted guide on this journey. Explore our resources, seek expert guidance, and empower yourself – after all, your health deserves it.

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