The purpose of buying a health insurance plan is to ensure that you stay financially covered in case of a medical crisis. You have to ensure that the claim against the insurance plan is settled quickly and with ease. When unexpected medical expenses arise, knowing the ins and outs of the claim filing procedure can make all the difference in swiftly obtaining the financial support you are entitled to. This guide will inform you of the crucial steps and vital information on effectively filing your individual health insurance claim in India.
Types of Health Insurance Claims
There are two types of mediclaim policy claims in India: cashless and reimbursement.
1. Cashless Claim
In a cashless claim against individual health insurance, you do not have to pay anything upfront to the hospital for your treatment, as the insurance company directly settles the bill with the hospital. This is convenient and hassle-free, as you do not have to worry about arranging funds or submitting documents later. However, to take benefit of a cashless claim, you need to follow these steps:
- Choose a hospital that is part of the insurer’s network of cashless hospitals. Review the list of network hospitals on your insurer’s website or by calling their customer care number.
- Inform your insurer about your hospitalisation as soon as possible, preferably within 24 hours of admission. You can do this by filling out an online form, emailing, or calling their toll-free number.
- Fill out a pre-authorisation form at the hospital’s insurance desk. Submit it along with your health insurance card and identity proof. The hospital will then send the form to the insurer or the third-party administrator (TPA) for approval.
- Wait for the authorisation from the insurer or the TPA. Depending on your case’s complexity and the documents’ availability, this may take a few hours or a day.
- You will receive an authorisation letter outlining the approved amount and pertinent details upon claim approval. If your claim is denied, a rejection letter will be provided, accompanied by an explanation.
- Get treated. You do not have to pay anything to the hospital except for non-medical expenses or co-payments not covered by your policy. The insurer will directly pay the hospital as per the approved amount.
2. Reimbursement Claim
A reimbursement claim is when you pay the hospital bills and then claim them back from the insurer later. This may happen when you choose a hospital not part of the insurer’s network or fail to get a pre-authorisation for a cashless claim. To obtain a reimbursement claim, you need to follow these steps:
- Notify your insurer about your hospitalisation within 24 hours of admission.
- Collect all the original bills, receipts, prescriptions, reports, a discharge summary, and other documents related to your treatment from the hospital. Make sure that they are complete and legible.
- Fill out a reimbursement claim form and attach all the documents with your health insurance card and identity proof. You can download the claim form from your insurer’s website or app or request it by email or phone.
- Submit the claim form and documents to your insurer or TPA within the stipulated time.
- Wait for the verification and approval from the insurer or TPA. Similar to cashless claims, you will receive an approval letter in your mail if your application is accepted and a denial letter in case of claim rejection.
- Receive reimbursement for your claim. The insurer will transfer the approved amount to the bank account you have registered with your insurer.
Tips to Avoid Claim Rejection or Delay
To ensure that your health insurance claim is processed smoothly and quickly, here are some tips to follow:
- Read your individual health insurance policy document carefully and understand what is covered and what is not covered by your policy. Avoid claiming any exclusions that are mentioned in your policy.
- Keep your policy details handy and update them regularly with any changes in your personal information, such as email id, address, and phone number.
- Follow the guidelines and timelines given by your insurer for informing them about your hospitalisation and submitting your claim documents.
- Check all your documents carefully before submitting them, and ensure they are original, valid, complete, and consistent. Avoid errors, discrepancies, or missing information that may raise doubts or queries from the insurer.
- Cooperate with the insurer or TPA during the verification process and provide any additional information or clarification that they may ask for.
- Track your claim status regularly and follow up with the insurer or TPA if there is any delay or issue.
Filing your health insurance plan claim in India is simple if you know the steps and follow them correctly. By selecting either a cashless or reimbursement claim based on your situation and adhering to the provided tips, you can ensure that your claim is settled without any hassle or delay. Health insurance is a valuable asset that can assist you in dealing with any medical emergency, so ensure that you use it wisely and effectively. The best health insurance providers usually have a high claim settlement ratio (CSR). Before finalising your individual health insurance plan or any other health plan, ensure the insurer has a good CSR. The higher the CSR, the higher the chances of your claim settlement, irrespective of the fact whether it is a cashless claim or a reimbursement.