Health Insurance Claim Process - Definition, Types, Process | Complete Guide

The Claim Process in a Health Insurance Policy can often feel overwhelming, especially during times of medical emergencies. Filing a Health Insurance Claim in the right way goes a long way in ensuring that the Policyholder receives a comprehensive settlement of medical expenses incurred under the Health Insurance Policy

What is a Health Insurance Claim?

A Health Insurance Claim is a request made by the Policyholder to avail compensation of his/her medical expenses as per the terms and conditions of the Health Insurance Policy. The Insurance Company upon verification of the Claim, either settles the bills directly with the hospital or reimburses the amount to the Policyholder.

The Insured can avail claim settlement in two ways under a Health Insurance Policy:

1. Cashless Claim Settlement
2. Reimbursement Claim Settlement.

This article describes both types of claims settlement processes in detail.

Types of Health Insurance Claims

Cashless Claims

Cashless Claim Settlement is a health insurance claim settlement feature offered by Health Insurance companies where the Insurance Company directly pays the hospital for the medical expenses incurred by the insured. This eliminates the need to arrange for funds during a medical emergency, thus providing peace of mind to the Insured. The hospital where the Insured avails treatment must be a part of the network of hospitals approved by the Insurance Company where the Insured can avail cashless claim settlement.

Reimbursement Claims

If the hospital where the Insured is availing treatment is not a part of the Insurance Company’s network of hospitals, the Policyholder will have to opt for a Reimbursement Claim. A Reimbursement Claim is one in which the policyholder pays the hospital directly, and then submits a claim to the Insurance Company for reimbursement. Reimbursement claims can be raised at both network and non-network hospitals. This Insured needs to submit the bills, diagnostic reports, Discharge Card and other necessary documents to the Insurance Company to avail a reimbursement under the Health Insurance Policy.

Health Insurance Claim Process

We will now look at the Claim Process for both, Cashless Claims and Reimbursement Claims.

Cashless Claim Settlement Process in a Health Insurance Policy

The step-by-step procedure to avail a Cashless Claim Settlement under a Health Insurance Policy is as follows:

1. Identify Network Hospital: The first step in a Cashless Claims Process is to choose a hospital that is part of your Insurer’s network. Check the policy document or the Insurance Company’s website to get the complete list of network hospitals.
2. Pre-Authorization Request: For planned hospitalization, inform the Insurance Company at least 3-4 days in advance and obtain the Pre-Authorization Form from the Insurer. Fill out your pre-authorization form and submit the form at the hospital’s insurance desk. For emergency hospitalization, get admitted to a network hospital and avail yourself of the necessary treatment. Inform the Insurance Company as soon as possible regarding the emergency hospitalization and fill out the pre-authorization form at the insurance desk of the hospital.
3. Approval of the Claim: Once the pre-authorization form is submitted, the Insurance Company reviews the medical documents to ensure the treatment is covered under the Policy. Depending on the Policy terms and conditions, the Claim may be approved, partially approved or rejected.
4. Final Settlement: Once the treatment has been availed at the network hospital, the hospital sends the final bill to the Insurance Company and the Company settles the bill directly with the hospital for approved claims. In case of Pre and Post-Hospitalisation expenses, the Insured needs to separately send the bills to the Insurance Company as part of a Reimbursement Claim.

Reimbursement Health Insurance Claim Settlement Process

When the Insured receives medical treatment at a non-network hospital he will need to raise a Reimbursement Claim under the Health Insurance Policy. The Policyholder should follow the below-mentioned steps to raise a Reimbursement Claim with your Health Insurance Company.

1. Receive Treatment and Intimate Claim: The Policyholder avails treatment at the hospital and settles the hospital bills out of his own pocket. The Insured has to inform the Health Insurance Company about the treatment and register a Claim under the Policy. The Policyholder collects the necessary documents from the hospital to submit the same to the Insurance Company.
2. File a Reimbursement Claim: Once the Policyholder is discharged from the hospital and has collected all the necessary documents, he has submit the same to the Insurance Company to avail a Reimbursement Claim Settlement under the Policy.
3. Approval and Reimbursement: Once the Insurance Company receives the necessary documents, the claim request will be verified against the terms and conditions of the Health Insurance Policy. Accordingly, the Reimbursement Claim may be approved, partially approved or rejected. In case of rejection, the policyholder will be notified regarding the reason for rejection.

What are the documents required for a Reimbursement Claim under a Health Insurance Policy?

The Insured needs to submit the following documents to the Insurance Company to avail Reimbursement Claim Settlement under the Policy:

1. ID Proof: A copy of the Patient’s ID proof (e.g., Aadhaar Card, Pan Card, Passport).
2. Claim Form: Duly filled and signed Claim Form provided by the Insurance Company.
3. Hospital Discharge Summary: A Discharge Summary mentioning the Treatment received and the duration of hospitalization.
4. Hospital Bills and Receipts: Original Hospital Bills and Payment Receipts, including break-up of charges.
5. Pharmacy Bills: Original bills for medicines purchased, along with prescriptions.
6. Doctor’s Prescription and Consultation Papers: Prescriptions and Consultation Papers from the treating doctor.
7. Pre- and Post-Hospitalization Bills: Bills and Receipts for expenses incurred before admission and after discharge from the hospital, as per the policy terms.
8. Diagnostic Reports: Original Diagnostic Test Reports (e.g., X-rays, blood tests, MRI scans) along with receipts.
9. Bank Details: Bank Account details for reimbursement, often including a canceled cheque.

Top Reasons for Health Insurance Claim Rejection

The top reasons for your Health Insurance Claims rejections are as follows:

1. Non-Declaration of Pre-Existing Diseases: A major reason for claim rejection is not declaring Pre-Existing disease at the time of purchasing the Policy.
2. Incorrect or Inadequate Documents: Another reason for Claim Rejection is the Policyholder’s inability to submit the required documents to the Insurance Company. Many a times, the Policyholder submits incorrect or inadequate documents.
3. Filing a Claim during the Waiting Period: Health Insurance Policies have Waiting periods before they begin to provide coverage for things like Pre-Existing Diseases, Specified Diseases, Maternity Benefits etc. Raising a Claim for the same before the Waiting Period ends results in Claim Rejections.
4. Filing a Claim for Excluded Causes: Some causes are excluded from Policy Coverage. For example, Medical Expenses incurred on account of usage of drugs or alcohol are typically not covered under a Health Insurance Policy. If the claim falls under the list of exclusions, the Policyholder’s claim will be rejected.
5. Late Submission of Documents: Delayed Submission of documents is also a significant reason for claim rejection.

How to avoid Health Insurance Claim Rejections?

Here are a few tips to avoid claim rejections under

1. Declare Pre-Existing Disease: The Insured should declare all Pre-Existing diseases and make sure they are recorded on the Insurance Policy.
2. Understand your Policy: The Insured should be aware of what is covered and not covered under the Health Insurance Policy. The Insured should make sure that the hospitals he avails treatment at are a part of the Insurer’s Network.
3. Notify the Insurance Company promptly: The Policyholder should notify the Insurance Company and register a Claim as soon as possible to avoid deduction or claim rejection for delayed intimation.
4. Submit Documents on Time: Make sure that to submit the all the necessary documents along with the Claim form.

Qian is a licensed Insurance Broker for Health Insurance Policies and can assist you in your claim settlement process. For help in purchasing the right health insurance policy with a seamless claim settlement process, reach out to Qian via email at insurance@qian.co.in or call us on 022-35134695. We would be glad to assist you.