How to claim Health Insurance? - Steps & documentation

3 min read Apr 17, 2024

Claiming your Health Insurance policy may seem daunting at first, especially if you or any of your loved ones have been through a serious medical procedure. If you need medical attention, knowing you have Health Insurance to rely on is comforting, provided you have the correct information on how to claim it. This article aims to simplify the Health Insurance claim process, ensuring you can access the benefits you're entitled to without unnecessary stress.

How to make a Health Insurance claim?

During a medical emergency or when you require healthcare services, promptly notifying your Health Insurance provider is crucial. Swift communication ensures adherence to your policy's guidelines for filing a claim.

Your insurer will guide you through the necessary documentation and the completion of claim forms. It's imperative to act quickly to facilitate a seamless claim process. Prompt notification to your insurer is key to a straightforward and efficient Health Insurance claim experience.

Cashless claim settlement

In a cashless claim settlement, the insurer directly settles the bill with the hospital. This facility is especially beneficial as it spares you the burden of upfront payment during stressful times. However, it's important to note that cashless service is typically available only within the insurer's network of hospitals.

Before proceeding with a cashless claim, double-check that the hospital is on your insurer's list for this service. This way, you can make the most of the cashless option without any hitches.

Reimbursement claim settlement

A reimbursement claim is when you pay for your medical care first and then ask your Health Insurance to pay you back. If you get treated at a hospital that's not part of your insurer’s network, or if you have already paid the bills, this is the way to go. Just keep all the receipts and submit them to your insurance company afterwards. They will check everything and refund the money you spent. It's a bit more work with the paperwork, but it allows you to pick any hospital you want for your treatment.

Health Insurance claim process

The pathway to claim Health Insurance benefits can be navigated more smoothly by understanding the detailed steps involved:

Cashless Health Insurance claim settlement process

For a smooth cashless claim experience with your Health Insurance, here's the process to guide you:

• Step 1: Take admission in a hospital that is part of your insurer's network; contact the insurance helpdesk.
• Step 2: Present the insurer's health card for ID verification.
• Step 3: The hospital provides pre-authorisation form for cashless service.
• Step 4: Submit the completed pre-authorisation form to the hospital's insurance desk.
• Step 5: The hospital sends the form to your Health Insurance provider.
• Step 6: Insurer reviews request and documents and approves cashless claim per policy.
• Step 7: At discharge, settle any non-covered expenses per policy terms.
• Step 8: The insurer settles the bill with the hospital as per the policy agreement.

Reimbursement Health Insurance claim settlement process

To initiate a reimbursement claim with your Health Insurance policy, simply follow these instructions:

• Step 1: Notify the insurer of hospitalisation promptly
• Step 2: Receive hospital treatment
• Step 3: Pay hospital bills at discharge, collect all necessary documents
• Step 4: Submit all documents i.e. original bills (bills for doctor fees, medicines, diagnostic tests, etc), doctor’s reports, discharge summary, reports of any diagnostic tests conducted, etc to the Health Insurance company
• Step 5: Insurer examines documents and processes claim per policy rules
• Step 6: Upon claim approval, the insurer reimburses the expenses

Documents required to file a Health Insurance claim

The success of your Health Insurance claim largely depends on the documentation you provide. Essential documents include:

• Duly filled claim form
• Medical certificate or report
• Hospital discharge summary
• Pharmacy bills
• Original invoices and payment receipts

Things to consider while applying for a Health Insurance claim

The Health Insurance claim process can be smooth and efficient if you keep a few critical considerations in mind. These facilitate a quicker claim processing time and ensure that you fully leverage your Health Insurance benefits.

• Make a claim in time: Most insurers have a specified timeframe within which you need to notify them about an incident to make a claim. This could be immediately or within a specified number of days post-hospitalisation. Adhering to these timelines is essential to avoid delays or denials in your claim processing. Early intimation gives the insurer adequate time to process your claim and, in cases of cashless treatments, coordinate with the hospital directly.
• Accuracy of information: Inaccuracies or incomplete information can lead to unnecessary delays or outright rejection of your claim. Ensure that all details, from personal information to medical bills and reports, are accurately presented. This includes disclosing the nature of the ailment, treatment details, and hospitalisation records. Double-check forms for errors or omissions before submission to streamline the approval process.
• Adequate coverage: Before you get any medical treatment, it's important to check that your Health Insurance will cover it. Policies might have exclusions or limits on certain treatments, medications, or medical procedures. Familiarising yourself with the terms and conditions of your policy ensures that you're aware of what's covered and what's not, thereby avoiding surprises during the claim process.
• Avail of cashless facility: The cashless facility is a feature that allows you to receive medical treatment without having to pay upfront. Instead, the hospital coordinates directly with the insurance company for payment. This facility significantly reduces financial stress during hospitalisation. To take advantage of this benefit, ensure that the hospital is part of your insurer's network.

Tips to avoid Health Insurance claim rejections

Ensuring your Health Insurance claim sails through without hitches involves a few prudent steps:

• Always disclose any existing health condition to your insurance company.
• Notify your insurer about any hospital stays, scheduled or unexpected, within the time frame they have set.
• Before filing a claim, familiarise yourself with the details of your policy, including what is covered, the waiting period, exclusions, and the claims process.
• Provide all necessary documentation and opt for a hospital within your insurer's network to use cashless claim services.

Also Read: Embracing peace of mind: Why personal Health Insurance is a must

Finding the right Health Insurance is important to look after your health and wallet. You have got a range of options, from Aditya Birla's plans that encourage a healthy lifestyle to TATA AIG's budget-friendly covers and Royal Sundaram's full family plans with Axis Bank. Select the health insurance plan that best suits you and your family's needs to ensure peace of mind regarding healthcare and focus on the joys of life.

Disclaimer: This article is for information purpose only. The views expressed in this article are personal and do not necessarily constitute the views of Axis Bank Ltd. and its employees. Axis Bank Ltd. and/or the author shall not be responsible for any direct / indirect loss or liability incurred by the reader for taking any financial decisions based on the contents and information. Please consult your financial advisor before making any financial decision.

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