Health Insurance Claim Process | Cashless & Reimbursement Claims

In a World full of uncertainties one has to plan for the unplanned events like the medical emergencies, hospitalizations. All though one has taken the Mediclaim or the Health Insurance policy understanding the claim process is an equally important task. People have become more aware of the health and Mediclaim policies which are an encouraging sign. One would do a good job as well of understanding the claim process as well.

A health insurance claim process gets underway when the policyholder or the covered person is admitted to health service provider which can be Hospital/ Super-Specialty Clinic for a medical treatment or emergency like a surgery. As soon as the health policyholder calls up the Third Party Administrator, the transaction between TPA and the insurance company starts. TPA collects all the medical bills and claims. At the time of treatment, the hospitals are responsible for the submission of the medical bills.

1. Cashless Claim Process:

In order to avail this service, the treatment has to given to the insured at one of the impaneled hospitals. When the policyholder provides the details of the health insurance policy like the e-card or any other physical proof of the health insurance policy taken by the policyholder, the insured would be able to get the cashless hospitalization and treatment. Once the patient is discharged, the medical bills are sent by the hospital to the insurance company. The company then verifies the bills and makes the payment.

The claims process for the Cashless treatment depends on the type of treatment which could be a planned or the unplanned one. Unplanned treatment is one which happens in case of an emergency.

Claims Process for the Planned Treatment at the Cashless Network Hospital:

In this type of treatment, the insured is required to inform the insurance provider ahead of hospitalization to avail this service. The insurance provider needs to be informed at least four days in advance before the treatment starts and also a cashless claim request form has to be submitted at the relevant address of insurance company. Once these steps are done, the insurance company would then inform the insured about the policy cove and the eligibility. The day the policyholder get hospitalized, he/ she needs to display his/ her policy card. The insurance company then contact the hospital to complete the further procedure.

Claims Process for Unplanned Treatment at the Cashless Network Hospital:

In event of an emergency, the policyholder can contact the customer care help desk of the insurance company for getting information on the nearest hospital. By submitting the health insurance card the policyholder can avail this service. The hospital would then take the process further by filling up the cashless claim request form and submitting to the relevant contact address of the insurance provider. An authorization letter would then be issued by the insurance provider to the hospital indicating the policy coverage. The hospital bills would then be settled by the health insurance provider directly to the hospital. In case of rejection of the claim, the policyholder would be informed with the reason being stated in the communication.

2. Reimbursement Claim Process:

In the event of the policyholder getting admitted to a hospital which is not in the empaneled list of hospitals of the health insurance provider, the policyholder would have to undertake a Reimbursement Claim process. In this, the process the insured person would first have to pay the medical bills and also the other costs involved in the treatment and then raise a claim. The policyholder under the reimbursement claim process would have to provide all the necessary documents which include all the original bills to the health insurance provider. The company would then evaluate the claim to see verify the coverage and in case of the claim being found legible makes the payment to the policyholder, in event of dismissal of claim the health insurance provider informs the policyholder of the result and states the reason in the communication.

List of documents which are required for making a health insurance claim:

  • Duly filled in the claim form.

  • Medical Certificate/ form which has been signed by the doctor

  • Prescription and also the Cash Memos from pharmacies/ hospital

  • Investigation Report

  • All original bills and receipts

  • Original Discharged summary or card availed from the hospital

  • If it’s an accident case, then the FIR or the Medico-Legal Certificate (MLC)

For exact details on coverage, inclusions, and exclusions, it is advisable to go through the policy document and contact your insurance company for clarity, in case of any clarifications required. Please note that the claim process specifics differ from one insurance company to another and also different for different types of illnesses. So it’s best to seek prior clarity, so as to avoid any confusion

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