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How to make a claim in your health insurance plan?

A health insurance policy comes to your aid in medical emergencies. It pays for the medical costs which you incur in case you or your family member gets hospitalized. The medical expenses can put a financial strain on you and when you have a health insurance plan, this strain can be minimized. That is why it is always recommended to invest in a good health insurance cover for yourself and your family.

While a health insurance plan can promise a good scope of coverage, you need to know the process of making a claim in your policy. Only when you follow the correct claim procedure can your health plan come to your rescue in a medical emergency. Many individuals are unaware of the claim process of health insurance plans and so here is the detailed guide to a health insurance claim process –

Types of health insurance claims

Health insurance claims or of two types – cashless and reimbursement. The cashless claim is when you seek treatments in a hospital which is tied-up with the insurance company. In such cases, the insurance company directly settles your medical bills with the hospital and you don’t incur the associated medical costs. Reimbursement claims, on the other hand, are incurred when you get treated in a non-network hospital. In such cases, you bear the medical expenses yourself and then get the expenses reimbursed from the insurance company.

The process of both these types of claims is mentioned below –

Process of cashless claims

  1. In case of any medical emergency which is covered under your health insurance plan, contact the insurance company to find the list of networked hospitals in your locality. The list can also be checked online on the insurance company’s website.
  2. Fill up a pre-authorization form for cashless treatments and submit it with the insurance company or its TPA (Third Party Administrator). The form is available at the hospital which is tied-up with the insurance company. The form should be filled and submitted within 24 hours of emergency hospitalization. In case of planned hospitalization, the form should be submitted at least 3-4 days before you get hospitalized.
  3. Based on the pre-authorization form, your cashless claim is approved by the insurance company
  4. Once the claim is approved, you would be able to avail cashless treatments at the hospital
  5. After you are discharged, collect all medical bills and reports from the hospital. Fill up a claim form and submit it with all the bills and reports for the full settlement of your claim.

Process of reimbursement claims

  1. If you are treated at a hospital which is not tied-up with your health insurance provider, you would have to pay all the medical bills from your own pockets
  2. Once you are discharged, collect the medical bills, reports and all hospital receipts
  3. Fill up a claim form and submit it with all the medical bills in original
  4. The insurance company would verify your claim and the associated bills and then reimburse you for the medical costs which you have incurred.

Documents required for a valid claim

Whether you avail a cashless claim or get reimbursement, the following documents would have to be submitted to the insurance company –

  1. The claim form, filled and signed
  2. Policy document
  3. Identity proof of the insured who is hospitalized
  4. Medical bills, in original
  5. Hospital reports and bills
  6. Doctor’s prescription which advised hospitalization
  7. Any other document as needed by the insurance company

Nowadays, health insurance companies have simplified their claim settlement process. They promise to settle your claims at the earliest if you follow the proper procedures and submit all the required documents. Especially in case of cashless claims, approvals can be received quickly if you fill and submit the pre-authorization form at the earliest. So, know the claim process of health insurance plans so that you can have a hassle-free claim experience when you suffer a claim.

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Published by Nidhi Mehra

I am blogger with 5 years of experience in writing articles and topics related to finance and funds

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