Health Insurance Claim: Tips to Make a Successful Claim

Over the past few years, medical expenses have increased significantly. So, a healthcare policy is no longer a choice but a necessity. It is vital in helping you get the best medical care without depleting your hard-earned savings.Having the right Health Insurance can make you feel relaxed. But the real test of how well your policy serves you is when you file a claim. You may have paid all your premiums in time, but there may still be reasons for your insurer to reject your claim. A rejection claim can devastate you as you might have to pay the medical expenses out of your pocket during an emergency.So, it is necessary for you to clearly understand the factors that could lead to your insurer accepting or rejecting your Health Insurance claim. Also read – How to make Health Insurance claims during emergencies Here are some tips for planning a worry-free, successful Health Insurance claim:There are primarily two ways to file a claim – cashless and reimbursement.

The cashless facility is the highlight of most health policies now. As the name suggests, it provides the convenience of receiving medical treatments at network hospitals with no upfront bill payments. If hospitalised, the insurance company settles the bills directly with the hospital. You do not have to pay any money out of your pocket.But there are a few things you still need to do. Below is the detailed process for filing a cashless claim:

Choose a network hospital:

The first step is to look at the list of hospitals within the insurer’s network. You can find the list in your policy document or ask your insurer for it. If the hospitalisation is sudden, and you must opt for a hospital outside the insurer’s network, the cashless facility may not be available.

Inform your insurer and TPA:

Whether planned or sudden hospitalisation, informing your insurer as soon as possible is always advisable. If your policy involves a Third-party administrator, inform them about the hospitalisation. Third-party administrators or TPAs , are service providers who assist insurance companies in processing your claims and other related administrative functions on their behalf.You must provide the policy number, patient details, and hospital details while informing both parties.

Request for pre-authorisation:

This step involves sharing your medical records, recommended treatments, and estimated costs with your insurer. If you have a TPA, the hospital coordinates with your TPA to send a pre-authorisation request to your insurance company.

Approval from insurer:

It is when your insurer evaluates your treatment needs and estimated expenses against your policy coverage. The insurer authorises the treatment if everything is in order.This step is crucial if hospitalisation involves expensive treatments or surgeries. It is possible that the insurer disagrees with the hospital on the treatment costs and imposes a limit on the cashless settlement. In such cases, you may have to shell out some money.The insurer sends an approval on pre-authorisation for your treatments to the hospital.

On discharge from hospital:

Once the hospital discharges you, check with the TPA for any additional documents you must submit. Your insurer pre-authorises the cashless facility and directly settles the bills with your hospital.If your pre-authorisation had any limits, you must pay the remaining amount and can later claim a reimbursement.

In this case, you must pay the medical expenses and claim the bill amount from the insurance provider. Here's the claim process for reimbursement health policies:

Pay for the treatment:

Unlike a cashless facility, you must pay all your bills at the hospital at discharge since you did not seek any pre-authorisation for the treatment. You need to be aware of your policy's exact inclusions and terms.As discussed, this method of filing your health claim is also applicable if you cannot access a hospital within the insurer’s network.

Inform your insurer:

For reimbursement claims, you can inform the insurance company after discharge from the hospital. But be extra careful in maintaining proper records for all the bills, receipts, test reports and doctor prescriptions.

Submit the reimbursement claim form:

Next, you need to submit a reimbursement claim form with details of the treatment and the costs incurred. You also need to submit all the bills and other documents related to the hospitalisation, along with the details of the patient and your health policy. You must submit these documents within a time specified by your insurer in your policy. The insurer can only accept your claim if you submit the details.

Verification and settlement:

The insurance company settles your claim if all the documents are in order and after it completes verification. If the claim gets rejected, the insurer issues a rejection letter with the reasons for rejecting the claim. Also read – What are the reasons why your Health Insurance claim may get rejected?

• A duly filled and signed claim application form.
• Doctor’s prescriptions indicate treatment at the hospital.
• Doctor’s reports on consultations, lab tests, and medical treatment.
• Hospital discharge summary
• Pharmacy bills
• Receipts linked to ambulance service
• First Information Report (FIR) copy, in case of accidental hospitalisation
• All relevant investigation reports mentioning the diagnosis.
• Health card copy.
• KYC documents like PAN and Hospital Registration Cards.

• Make sure you fill out the application form yourself. People often ask their representatives or agents to fill out the Insurance application. However, this is not the best thing to do, as they leave room for mistakes.
• Disclose all health-related information you can to the insurance company. Be transparent about medical conditions and even you're smoking or drinking habits, as it will smoothen claims processing in the future.
• In case of any past medical condition such as illness or chronic diseases, be open while filling out the application form. These conditions add to your ailments list, and you can make a Health Insurance claim later.
• Another critical Health Insurance tip is to inform the company about your organisational hazard, if any. For instance, if you work in a sedentary job and are prone to health diseases, you might need to pay a premium covering your safety and security of yourselves.
• Always handle medical invoices, bills, prescriptions, and other documents carefully. The insurer asks these documents to ensure your Health Insurance claim is successful.

There are a few conditions under which the health insurer may reject your claim. Here are a few such situations:1. If you fail to inform the insurer about your medical emergency or hospitalisation within the period specified in your policy document, the insurer might reject your claim.2. The insurer can reject the claim if you have exhausted your policy coverage limit, which can happen if another insured member of your family used up your Family Floater plans. Multiple claims might exhaust your limit, leading to claim rejections.3. If you fail to submit all the necessary documents related to the hospitalisation, the insurer can reject your claim. Also read – How to file claims if you have multiple Health Insurance policies

• There are two ways to file a claim: cashless and reimbursement.
• Cashless claims involve treatment at network hospitals without upfront payments.
• Reimbursement claims require paying the expenses and claiming the amount from the insurance provider.
• While filing a claim, include all necessary documents within the specified time frame.
• The insurer verifies the claim and settles if documents are in order.
• Your insurer can reject claims if not informed within the specified period, the policy coverage limit is exhausted, or necessary documents are not submitted.