Guidelines for Successful Health Insurance Claim

People are of the view that health insurance claim process is too tedious and non-transparent, therefore desist from buying health insurance. They are very tense when they get into the process of filing claim. They have repeatedly complained to the Insurance regulator and health insurance providers of the complexity they experience at the time of filing of the claims.

But it has to be said that some of them are genuinely difficult cases and many unfortunate cases arise due to the customers misunderstanding the value of the correct details that have to be provided to the insurance company in India which has to be given by the customer while buying the policy online or from an insurance agent.

Pathway to Successful Health Insurance Claims:

Health Insurance claims can be processed in two ways.

  1. Cashless Settlement

You are entitled to Cashless Treatment at any of the hospitals falling in the PPN (Preferred Provider Network) list of the health insurance providers. Here the Third party Administrator / Insurance Company settles the cost of treatment and any subsequent expenses with the hospital without involving you.

  1. Reimbursement of Medical Expenses

In case you have a medical emergency and decide to get treated at a hospital not present in the PPN (Preferred Provider Network) list of the health insurance provider, then you have to pay the expenses out of your own pocket and then make a claim for reimbursement. In view of the massive cost attached with treatment, this reimbursement option might not be preferred choice for many.

Claim Process for Cashless Settlement:

  • The insurance company needs to be intimidated at least 2-3 days in advance and minimum 24 hours in case of medical emergency.

  • You should contact the Third Party Administrators (TPA) as they assist both the insurance company and you in terms of documentation.

  • Once the documents are received by the health insurance providers then the company looks into the case against the coverage and terms and conditions.

  • The insurance company decides on the case and lets the policyholder know of its decision.

  • If the cashless treatment application is denied then you have to pay the costs from your own pocket and later on raise a case for reimbursement.

Claims Process of Reimbursement of Claims

  • You still need to inform the insurance company even if you decide to undertake the process of reimbursement process

  • Submit the required documents to Third Party Administrator (TPA) to kick start the process and they will further take it forward to the insurance company,

  • Post submission of the required documentation your claim will be scrutinized and the claim would be accepted/rejected based on the terms and conditions of the policy.

  • If the Claim is accepted then final amount arrived at by the insurance company is paid along with the Claim Settlement letter mentioning the breakup amount.

  • If the claim is rejected. Claim Rejection letter is sent with reasons mentioned in the letter.

Important Points to Consider for Health Insurance Claims

  • 24 hours of hospitalization is mandatory to make a health insurance claim

  • Every health insurance company has a time frame, you need to follow them to get a successful health insurance claim

  • Have a clear understanding of what’s covered and what’s excluded in your plan

  • Maintain a proper file of prescriptions, medicines.

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