How To Claim Health Insurance?


You have gone through the tedious process of buying the best health insurance policy, but when it comes to claiming a health cover, it can become a bit challenging. This is true, especially when you’re placing a claim request for the first time. With proper awareness, you can do it peacefully. Read further to know how to claim for health insurance. 


Health insurance is useful when you know how to claim. Do you fear that your request may get rejected due to inevitable reasons? Then, you need to understand the process. There are two ways to claim for health insurance – Cashless and Reimbursement.

Cashless process:

Under this process, you can seek cashless settlement if there is planned hospitalization. Note that it is available only at the network hospital of the insurance company. A network hospital means insurance companies have a tie-up with individual hospitals in a specific area wherein the company will incur expenses related to hospitalization. You can request for a cashless claim in health insurance in case of both planned and unplanned admission. 

Steps to follow for planned admission 

  1. Select the network hospital 
  2. Inform third-party administrator (TPA) or insurance company three days prior if there is planned hospitalization
  3. You can also call TPA for claim request by giving your policy membership number
  4. Submit a cashless claim request form along with medical reports. The insurance company or TPA will evaluate the request and convey their approval to the hospital
  5. After approval, the company will settle the hospital bills directly 
  6. If the application is rejected, you would have to pay the hospital bill and apply for reimbursement 

Steps to follow in case of emergency admission:

  1. In case of emergency, inform the TPA and provide the policy membership number
  2. Fill the form of cashless claim form at the hospital insurance helpdesk and get it signed by the treating doctor 
  3. Submit the form and the supporting medical reports via email or fax to the TPA or insurance company
  4. Once the hospital receives approval, you can avail cashless treatment 
  5. In case it is not approved by the TPA or insurance company, you can file for reimbursement request post-discharge. 

Reimbursement process: 

In case your cashless claim is rejected, you can choose for reimbursement. Below are the steps for the same:

  1. Inform the insurance company or the third party about the hospitalization 
  2. Avail treatment & pay all the hospital bills 
  3. Fill the reimbursement request form
  4. Submit the form along with essential documents (discharge summary, hospital bills, prescriptions, advance and final receipts, diagnostic test reports, X-ray, scan and ECG) to the insurance company or the TPA

The insurance company dispatches a cheque if the claim is approved; in either case, the insurance company sends a repudiation letter. The usual turnaround time for the process is 20 days.

Frequently asked questions about claims:

Knowing how to claim health insurance is important! It ensures that, in case of a medical emergency, you can get the treatment you need without having to worry about the cost. However, even after knowing how to make a claim, you might still have some queries about the process. Keeping this in mind, the following article will also answer some of the most commonly asked questions about health insurance claims

What happens to the coverage of my plan after a claim is filed?

After a health insurance claim is filed and successfully settled, the coverage of your policy is reduced by the amount that has been paid out on settlement. For instance: In February, you start with a policy that provides coverage of Rs 10 Lakh for the year. Then, in May, you make a claim of Rs 4 lakh for an operation. In this case, from June to February in the following year, you have coverage worth Rs. 6 lakhs still available to you!

What are the documents required while making a claim?

The documents required to make a claim would depend completely on the kind of claim you make. In case you opt for a cashless claim, you are only required to fill the form at the hospital’s TP desk. However, in case of reimbursement, you would have to provide the duly filled claim form along with all the health invoices that you want compensation for.

Is there a limit on the number of claims I can make in a year?

You can raise several claims during the policy period. This is because there is no limit on the number of claims you make. However, the coverage of your policy is limited to its sum insured. Once you have exhausted the sum insured of your policy, you cannot make further claims.

What if I don’t claim against my health insurance policy?

Most health insurance companies will offer you a No Claim Bonus. This is like a reward for not making a claim. This reward can be provided to you in 2 ways. Either your sum insured will be increased by a certain percentage, or your premium will be lowered by a certain percentage. This benefit will be provided to you every year, as long as you do not claim your health insurance policy. 

How do I ensure successfully claim settlement?

To begin with, you should opt for a good health insurance company, one with a good claim settlement ratio and a higher number of cashless garages. This will ensure you have a better chance of your claim being settled and a smooth settlement process. In this regard, some health insurance companies have a claim settlement ratio as high as 92% and more than 5000 network hospitals across India.

Also, when buying a policy remember to disclose all your health-related details. Do not hide pre-existing illnesses, smoking, or drinking habits. This could cause issues when you make a claim. If possible, get treatment at a network hospital so you can enjoy the convenience of a cashless claim. However, in case of reimbursement, remember to intimate your insurance provider on time and file the claim on time along with all the right documents.

So, the next time you want to claim for health insurance, you know how to start the health insurance claim process. Whether you want cashless or reimbursement, you can choose either of the one depending on the situation.