How to Claim Health Insurance? A Step-by-Step Guide
Types of Health Insurance Claims
When it comes to using your health insurance, there are mainly two ways to raise a claim: Cashless claims and Reimbursement claims. Understanding how both work can help you choose the right one based on the situation.
In a cashless claim, your insurance company directly settles the bill with the hospital. This means you don’t have to pay anything out of pocket at the time of discharge, as long as the hospital is part of the insurer’s network. These are known as network hospitals. You just need to show your health insurance card and follow the required process at the hospital's insurance desk.
If you are admitted to a hospital that is not tied up with your insurance provider, then you’ll need to pay the bills yourself first. After getting discharged, you can raise a reimbursement claim to get that money back from your insurer. You’ll need to submit all original bills and documents to support your claim.
Understanding TPAs and In-House Claims Processing in Health Insurance
When it comes to settling a health insurance claim, there are usually two ways the process works. Either your insurance company handles it through its own in-house claims team, or it uses a Third-Party Administrator, also known as a TPA. Both options are used to process your claim as per the guidelines set by the IRDAI, but each works a little differently.
What is a TPA?
What is an In-House Claims Processing Department?
Documents You Will Need for a Claim
To make sure your claim goes smoothly, you’ll need to submit the right documents. Here’s what you should keep ready:
How to File a Health Insurance Claim
Now, let’s look at how to file a health insurance claim. The process is slightly different depending on whether you go for a cashless claim or a reimbursement claim.
1
Cashless Claim Process
There are 2 situations where you might go for a cashless claim: planned hospitalisation and emergency hospitalisation.
A
Planned Hospitalisation
If you already know about your treatment in advance, like a scheduled surgery or admission, then this is considered a planned hospitalisation.
Here’s what you need to do:
Inform the Insurance Company
Get the Pre-Authorisation Form
Submission of Form by Hospital
Insurer Reviews the Request
Treatment Begins
Photocopy All Bills and Reports
Final Bill Settlement and Discharge
Keep in Touch with the Insurance Desk
B
Emergency Hospitalisation
In case of sudden illness or accidents, the claim process changes slightly since there is no time to plan.
Get the Patient Admitted
Inform the Insurance Company
Submit Pre-Authorisation Form Within 24 Hours
Monitor Approval Status
Treatment and Discharge
2
Reimbursement Claim Process
If you’re not using the cashless route, follow these steps to get your money reimbursed:
Collect All Necessary Documents
Fill and Submit the Reimbursement Claim Form
Claim Review by the Insurer
Keep Copies for Reference
Get the Amount in Your Bank Account
Common Reasons for Claim Rejection
Filing a health insurance claim can already feel stressful, and the last thing you want is for it to get rejected. Unfortunately, many claims are turned down for reasons that could have been easily avoided. Here are some of the most common ones to watch out for.
Read Your Policy Document Thoroughly
Don’t wait until the last moment to understand what your policy covers. Sit down with your policy document and go through it calmly. Look at the list of inclusions, exclusions, waiting periods, and claim rules. Knowing this in advance will help you avoid confusion later and give you more control over your claim process.
Delay in Intimation or Submission
Timing matters a lot. If you delay informing your insurer about a hospitalisation or take too long to submit the required documents, your claim may be turned down. Most policies have a specific window for raising a claim. If you miss it, there’s little that can be done. So, whether it’s a planned surgery or an emergency, try to alert the insurer at the earliest.
Treatment Not Covered
Not every treatment or procedure is covered under every plan. Sometimes, a claim is rejected simply because the treatment isn’t included in your policy. This is why it's so important to understand your policy from the start. Before going ahead with any expensive medical treatment, always check with your insurer if it’s covered.
Lapsed Policy
It’s easy to lose track of renewal dates, especially when life gets busy. But if your policy has lapsed due to non-payment of premium, your claim won’t be accepted. Even if the treatment is genuine and necessary, the insurer cannot help if your policy isn’t active. Set reminders or opt for auto-debit so you don’t miss renewals.
Things To Keep In Mind To Avail A Health Insurance Claim
Here’s what you should always keep in mind when you’re filing a health insurance claim.
1
Read Your Policy Document Thoroughly
Don’t wait until the last moment to understand what your policy covers. Sit down with your policy document and go through it calmly. Look at the list of inclusions, exclusions, waiting periods, and claim rules. Knowing this in advance will help you avoid confusion later and give you more control over your claim process.
2
Track Claim Status Online
Most insurance companies offer online claim tracking now. Use this tool to your advantage. It’s the easiest way to stay in the loop, check if your documents have been received, and see where your claim stands. This reduces uncertainty and gives you peace of mind.
3
Follow Up Regularly With the Insurer Or TPA
Sometimes, a claim might get stuck due to a small issue like a missing signature or an unclear bill. Following up regularly can help speed things up. Call or email your insurer or the Third Party Administrator (TPA) to make sure everything is moving along. It also shows that you are actively managing your own case.
4
Hospitalisation Intimation Period
Whether your hospital visit is planned or due to an emergency, informing your insurer on time is important. Most policies require that you notify them within a certain number of hours after being admitted. Not doing this can lead to unnecessary complications. If you’re unable to do it yourself, ask a family member to take care of it right away.
5
Claim Submission Window
After you’re discharged from the hospital, there’s a deadline for submitting all your documents. Don’t delay this step, thinking you have plenty of time. The sooner you submit everything, the sooner your claim gets processed. Make sure to keep all bills, discharge summaries, prescriptions, and reports safe and ready to go.
6
Expected Settlement Time
Each insurer has a different timeline for claim settlement. Knowing this helps you manage expectations. Some claims get processed in a few days, while others may take a couple of weeks, depending on the case. If things are taking longer than expected, don’t hesitate to follow up and ask for a status update.
How to Check the Status of a Health Insurance Claim?
Here's how you can check the status of your Insurance claim:
Your Health Insurance Claim Status for Cashless Claims
| Approved | Rejected / Denied | Query Raised |
|---|---|---|
| Once the claim is approved, your insurance provider informs the hospital directly. | If your claim is denied, either you or the hospital will receive a formal letter explaining the reason. | If your claim needs more clarity, the insurer will ask the hospital for extra documents or information. |
| At the time of discharge, you only need to settle the amount that isn't covered by your policy, like non-payable items. | In case of rejection, you will have to pay the entire hospital bill from your own pocket. You can later try to appeal the decision. | The hospital's team usually replies to these queries by sending the required documents or clarifications. |
| All the original papers related to your treatment are collected and kept by the hospital. | Even after denial, you can request a review or re-submission, especially if you believe the rejection was not justified. | Once the insurer is satisfied with the response, the claim is processed further, and approval may follow. |
Your Health Insurance Claim Status for Reimbursement Claims
| Approved | Rejected / Denied | Query Raised |
|---|---|---|
| If your claim is approved, you'll receive a settlement letter from the insurance company. This letter will mention the final approved amount and a cheque or bank transfer will follow. | If your claim is not accepted, the insurance company will send you a rejection letter. This letter will explain the reason behind the denial. | Sometimes, the insurer may ask for more documents or clarification if something is missing or unclear. This is called a query. |
| The process ends here unless you have any issues with the disbursed amount. | If you believe the rejection was unfair, you can raise a dispute or grievance with supporting documents. | You'll need to respond to the query and send the required details within the timeline given. |
| Once you submit the necessary documents, the claim process will move ahead accordingly. |
