Health Insurance Claim Process

Health Insurance Claims arise due to Sickness/Illness/Accidents.

What to do in the event of a claim

For cashless claims:

  • Soon after admission in the Hospital submit the ID card issued by Insurance Company to the claims department in the hospital.
  • Also submit a copy of the policy.
  • Ensure that the hospital claim department send the preauthorization form to Insurance Company/TPA.
  • Provide necessary queries.

For reimbursement claims:

  • Intimate Insurance Company.
  • Collect all originals like blood test reports, ECG, X-Ray, MRI, CT Scan, etc.
  • Complete the claim form, attach the originals and hand it over to the Insurance Company.

What does health Insurance cover in India:

  • Expenses that require hospitalisation for Illness/Diseases are only covered and certain Insurers offer additional cash benefits when in the hospital.
  • The basis of any health Insurance should be- Identification of a disease- Cost of treatment which includes room rent - cure from the disease.

Advantages of Health insurance offered by Life Insurer:

  • Because of the long term nature of the plans, the policy holder can plan in advance his future medical/care expenses. But it is not so under general insurance. Since, the general insurance policies are subject to renewal every year, if the policy holder has been making several claims and is considered a risk, the general insurance company may deny renewal or renew it for a much higher premium.

Advantages of Health insurance offered by General Insurer:

  • Though a lump sum amount is paid by life insurers and is of long term nature, this comes with a cost. They charge bigger premiums compare with the general insurers. In addition, most general insurance companies offer medical charges up to 30 days before a person is hospitalized and pay the claims if a person has been undergoing treatment at home - also called domiciliary hospitalization. The life insurers seem to lack this facility at this point in time.

How to make a Claim ?

Emergency Cashless Hospitalisation:

  • Submit your ID card issued by the Insurer/TPA to the Insurance Department of the Hospital.
  • Submit a copy of your latest policy with the ID card.
  • Ensure that the Insurance department in the hospital sends the pre-authorisation form duly completed to the Insurer/TPA.
  • In case the hospital wants you to give the claim number make a call to the toll free numbers mentioned on the ID card and tell them the details such as policy number, name of the person admitted, nature of illness. The Insurer/TPA will give you the claim number and inform the same to the hospital Insurance department who will send the pre autorisation form to the Insurer/TPA for further process.
  • Kindly note the Insurer/TPA will authorise the claim if the same does not fall in any of the exclusions like Diseases not payable in the first year/diseases not payable in the second year and Pre-existing diseases. Pre existing diseases are payable on completion of 4 continuous years of the said policy.
  • Kindly note there will be some expenses that will not be payable by the Insurer/TPA as per the policy conditions and the same have to be borne by the claimant.
  • On completion of the said treatment the Insured/Claimant may have to sign a form for having received the treatment with the amount claimed by the hospital.

Planned Cashless Hospitalisation:

  • In certain cases where there is no requirement for emergency hospitalisation the planned hospitalisation can be followed. For Eg. Tonsilitis surgery, Cataract surgery can be done on getting the authorisation from the Insurer/TPA. In such cases do as follows:
  • Submit the ID card and current policy copy to the insurance department of the hospital.
  • The hospital Insurance department in turn will send the same to the Insurer/TPA for authorisation along with the pre-authorisation form. On receipt of the authorisation the hospital will inform of the authorisation for the said surgery/treatment. Then complete the treatment.
  • Kindly note the Insurer/TPA will authorise the claim if the same does not fall in any of the exclusions like diseases not payable in the first year/diseases not payable in the second year and Pre-Existing Diseases. Pre existing diseases are payable on completion of 4 continuous years of the said policy.
  • Kindly note there will be some expenses that will not be payable by the Insurer/TPA as per the policy conditions and the same have to be borne by the claimant.
  • On completion of the said treatment the Insured/Claimant may have to sign a form for having received the treatment with the amount claimed by the Hospital.

Reimbursement Claims:

There may be some hospitals that may not have the cashless facility. In such cases the Insured/claimant has to make a reimbursement claim. The following procedure is to be followed:

  • Inform the Insurance company/TPA immediately on admission to the hospital to their Toll free number and obtain a claim number.
  • Collect the claim form from the Insurance Company/TPA and, where required get the claim form filled by the medical practioner at the columns duly filled in

Obtain the following from the hospital:

  • Discharge summary.
  • Final hospital bill with the payment receipt.
  • Detailed hospital bill which will indicate the details of room rent, consultants fees, medicines supplied by the hospital, investigation charges etc.
  • All investigation reports in original. In case certain investigations like MRI scan may have to be taken from a place outside the hospital. In such cases have a copy of the requisition form given to the outside institution for doing the respective investigation.
  • In case medicines are purchased from a pharmacy outside of the hospital keep the prescription along with the bill.
  • Request the hospital to give a copy of the indoor case sheet since some Insurers/TPA may require you to submit the same.
  • Submit all the papers aforesaid with the duly completed claim form to the Insurance Company/TPA for further process.
  • After having submitted the papers the Insurance company/TPA may require clarification on the line of treatment, duration of the illness, comorbid conditions etc. On receipt of the letter from the Insurance company submit the same at the earliest for further process.

Kindly note the Insurer/TPA will pay the claim if the same does not fall in any of the exclusions like diseases not payable in the first year/diseases not payable in the second year and pre-existing diseases. Pre existing diseases are payable on completion of 4 continuous years of the said policy.

Kindly note there will be some expenses that will not be payable by the Insurer/TPA as per the policy conditions and the same have to be borne by the claimant.

Also kindly note that the same applies to claims where the cashless hospitalisation claims are rejected or have been asked to come for reimbursement.

In the event of Claims being repudiated by the Insurance Company the following options are available as a recourse:

  • Make a representation to the Insurance Company/TPA.
  • If no reply is received within 15 days on making such representation make a representation to the Grievance Cell of the Insurance Company.
  • If No Reply is received or if the reply is not satisfactory then make a representation to the Insurance Ombudsman who has Quasi Judicial powers to hear the case and make adjudication.
  • If still not satisfied the next option is to go to court.