Health Insurance Claim Process
There are different claim processes based on the type of claim you are making with your health insurance provider.
- Cashless facility: In this facility company settles the medical treatment cost of the insured in the network hospitals of the company. Insured is provided with a cashless card at the time of policy purchase which the insured need to extend to the network hospitals along with valid ID proof at the time claims are being made .Approval for cashless is provided by the Insurer after the pre authorization form is submitted to the insured in electronic form.
- Reimbursement: In such case, Customers pay the bills for hospitalization on their own and later, get reimbursed from the insurance company after suitable documents are submitted to the company.
Claim Process for Cashless Hospitalisation:
1) Inform your insurance provider about the need of hospitalisation.
2) Get admitted to a network hospital and present your health insurance id card to the third party administrator (TPA) desk or claim desk present in the hospital to access your insurance details.
3) Insurance company/TPA will get in touch with hospital authorities to fill up a pre-authorisation form with the all treatment details, medical scans, other required documents, etc. and send it to the insurer for approvals.
4) The insurer will check the documents, once satisfied with documents and eligibility for cashless claim, they will send a go-ahead to the network hospital to give the treatment.
5) At patient discharge, the medical facility will send all the bills along with complete health and medical records and any other documents, if needed, to the insurer for final claim settlement.
6) Deductibles, co-payments and other exclusions mentioned in the policy will not be paid by the insurer, rest payments will be made to the hospital.
Claim Process for Reimbursement from Single Insurer:
1) At the time of hospitalisation, send the information to your insurer.
2) Once the treatment is done, fill the claim form available at insurer's website.
3) Attach all relevant and required documents such as medical reports, hospital bills, discharge summary and any other supporting documents in original, with the claim form and submit to insurer.
4) Keep all the health and medical documents, in case they are required by the insurer.
5) Follow up and coordinate with the company or TPA to make sure all the documentation is complete and claim is processed.
6) If everything remains in order, your health insurance claim should be approved in 30-40 days
Claim Process For Reimbursement from Multiple Insurers:
1) At the time of hospitalisation, send the information to all the insurers.
2) After getting discharged, select the insurance provider with which you want to file the claim first and fill their claim form.
3) Attach all relevant and required documents such as medical reports, hospital bills, discharge summary and any other supporting documents in original, with the claim form and submit to first insurer.
4) For multiple claims with multiple insurers, photocopies are not acceptable as per terms of the claim. Make sure to collect multiple attested copies of all documents from the hospital to be submitted to other insurers.
5) Once the first insurance company settles the claim, they will issue a letter confirming that they have the original documents, and the claim is settled.
6) Attach this letter with the form and set of documents, to be submitted to the second insurer. In a cover letter, state clearly that you have received X amount from another insurer against your claim!
7) Follow up and coordinate with TPA to make sure all the documentation is complete and claim is processed.
8) If everything remains in order, your health insurance claim should be approved in 30
9) For more insurers, repeat the same process.
Remember, if your documentation is in order and you have taken care of all the requirements, no insurance company can deny your health insurance claims.