How to Submit a Health Insurance Claim

Health Insurance protects you against unforeseen hospitalization expenses. Today, almost all health insurers offer cashless treatment facilities and reimbursement of hospital expenses facilities. For smooth settlement of a health claim, one should carefully follow all the steps described by his/her insurance company for instance; It is advised by some health insurance companies to inform about insured person within 24-48 hours after he/she is hospitalized; if no one informs within this time period, then an insurance company may refuse to settle claim (See- Medical conditions that your health insurance policy doesn’t cover); and in such scenarios, there are very rare chances of getting a claim settlement.

Health Insurance Claim

There are two ways to file a mediclaim under health insurance plan-

Cashless Claim: In this type of claim, insured person can obtain health services without paying anything from his/her pocket. Insurance company pays for all the hospital and medical expenses within the insured value. Policyholder receives a list of network of hospitals from his/her insurer where he/she can visit to avail cashless treatment facilities along with a “Health Insurance Identity Card” to avail cashless services.

Reimbursement Claim: Insured person may be taken to out-of-network hospitals whenever a medical emergency arises. In such scenarios, anyone can inform concerned health insurance company within 24 hours of admission; after the patient rushed to the nearest hospital. In reimbursement claim, patient pays for all the hospital expenses; and after availing treatment for an injury or illness, policyholder produces required documents such as; admission form. treatment list, all bills in original form along with discharge certificate, to the insurer to claim for reimbursement of expenses incurred in the hospital. Policyholders can also visit non-empanelled hospitals without any emergency if they wish; and later on, can file a claim.

Tips for Easy Mediclaim settlement-

  • Always prefer to visit empanelled hospitals for hassle free claim settlements except in case of emergency.
  • Read your policy documents carefully and see list of empanelled hospitals in your area
  • While getting treatment from non-empanelled hospitals, keep all the documents and bills of treatment to get a hassle free claim settlement.
  • Inform your health insurer as soon as possible and ask for the procedure to file a claim
  • Take all the required policy documents with you, such as Health Card, Policy Brochure etc.

Methods to File a Health Insurance Claim-

#1 Cashless Claim Procedure:

You can avail cashless treatment facility if it’s provided by your insurer. Here is the procedure to file a cashless claim under health plan:
Visit Empanelled Hospital: First of all, visit your closest network hospital. You may visit your insurer’s website to get a list of network hospitals or may call at customer service number.
Present Your Health Card: Tell the hospital that you want to avail cashless facility and show your health card issued by your insurer; you may need to submit the form to the hospital help desk or fax it to the designated number (ask the hospital about it). In cashless facility, you do not need to do anything else, however, you may call to customer service department to make sure that whether you are availing cashless facility or not.
Claim Process: After verifying your identity and policy documents, Hospital will start the treatment
Payment to The Hospital: After discharging you, hospital will send the bills to your insurer and after paying all the bills, you’ll be informed about the treatment expenses.

#2 Reimbursement Claim Procedure:

If the insured person is getting treatment from out-of-network hospital then he/she should strictly follow the guidelines issued by the authority to file a reimbursement claim. Here are the steps to file a reimbursement claim under health insurance.
Inform Your Health Insurance Company: Firstly and most importantly, inform the health insurance company that insured person has been hospitalized; you may inform through call, email, and post. These days many insurance companies offer online claim submission; therefore, you should visit your insurer’s website and if he offers online claim submission then just fill out your claim request; meanwhile, you may also use other methods. Some renowned insurers assign field doctors to help policyholders get treatment in a non-empanelled hospitals.
Keep All The Documents: Keep all the original documents and bills relevant to the treatment. You will need to submit original documents or copies of them while filling out the claim form.
Pay Your Hospital Bills: Upon discharge, pay your hospital bills.
Collect Bills and Discharge Certificate: After paying for the treatment, collect your bills and original documents from the hospital. Do not forget to collect discharge certificate.
Submit a Claim: Submit a reimbursement claim with original hospital documents (Don’t forget to keep copies of all documents) to your nearest office of health insurance company.

Claim Settlement: Within specified time limit, your insurance company will inform you whether your claim is accepted or rejected. In case, insurer rejects your claim then you will be notified by a letter; along with the reason for rejection.

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