AAROGYA CARE
August 6th, 2021
3 mins read

Making a Health Insurance Claim? Follow These Simple Yet Important Steps

You can make a cashless or reimbursement health insurance claim

Cashless claim covers both planned and emergency care at network hospitals

Keep all the necessary documents handy to make a health insurance claim

Health insurance nowadays has become a necessity more than a luxury [1]. It protects you and your family against unforeseen and planned medical expenses. In present times where health expenses have risen sharply, it is important for you to choose a health policy after careful scrutiny. One of the factors to consider is the claim settlement ratio [2] of the health insurance provider. This shows you how much the insurer honors its commitment. After all, you can only benefit from your health policy if you are able to claim it successfully.

You may be under the impression that a mediclaim or medical claim policy is complex. However, things have changed for the better and the convenience you experience depends on your provider. There are usually two health insurance claim ways that you can opt for while purchasing the policy itself. Read on to find out more and learn the steps of making a health insurance claim successfully. 

Ways to Claim Health Insurance

  • Cashless claim 

A cashless claim is one where you get treated at a network hospital on your insurance provider’s list. Under this facility, your insurer settles the bill amount directly with the hospital. A cashless claim can be availed for both planned and emergency treatments at a network hospital.

  • Reimbursement claim 

Under the reimbursement facility, you pay the bill upfront at the hospital and claim the amount later from your insurance provider. In this case, you can claim reimbursement for the treatment done at both network and non-empaneled hospitals.

Additional Read: Need of Health Insurance: Top Reasons Why Term Insurance Isn’t Enough 

how to make an insurance claim

Health Insurance Claim Steps for a Cashless Process 

  • Check the network hospitals list and diseases/treatments covered 

To avail a cashless claim, you are required to get hospitalized at a facility that is on the insurer’s network. So, check if the hospital you intend to visit has a tie-up with the insurer and if the ailment or injury you are getting treated for is covered under the policy.

  • Inform the hospital and the insurer 

Provide your ID and health insurance card at the insurance helpdesk in the hospital. Inform your insurance provider about your hospitalization status too. The hospital may ask you to fill the pre-authorization form at this stage.

  • Submit the necessary documents 

Submit all your treatment bills, medical reports, and other required paperwork such as ID proof along with the claim form at the counter. The hospital will forward your form to your insurance provider for settlement.

  • Keep a record of the approval and documents 

Your insurer will check all the submitted documents in accordance with the terms and conditions of the health or mediclaim policy. Some providers assign a field doctor to review and verify the claim. On approval, your insurer will settle the claim directly with the network hospital. It is best for you to keep track of the approval and maintain copies of the documents submitted. This will help you know the sum assured amount remaining at your disposal.

  • Check for pre and post-hospitalization cover 

Check if your medical policy covers pre- and post-hospitalization expenses. If so, submit the medical prescription, reports, and other documents within 30 days to your insurer.

Keep in mind that you will need to pay for all expenses not covered by the policy on your own to the hospital. Also, if opting for a planned hospitalization, contact the insurer and submit the pre-authorization form in advance. 

Health Insurance Claim Steps for Reimbursement

  • Intimate your insurer 

Let your insurance provider know about your hospital admission and treatment. Check to confirm if the treatment is covered under the policy. Pay the bills upfront at the hospital.

  • Fill the claim form and submit bills and reports 

Once you are discharged and have paid the bills, fill a claim form and submit all the documents including medical bills, prescriptions, and hospital reports to your provider. Attach the discharge card or summary report to your insurer too. Your insurer will then review the documents with the terms of your health policy and verify them. Once approved, the insurer will reimburse the amount to you.

  • Submit post-hospitalization bills and prescriptions 

If your policy covers post-hospitalization expenses, submit the doctor’s prescriptions and post-hospitalization bills to your insurer within 30 days. Some insurers also offer a window of 90 days to 120 days for this.

  • Keep copies for future reference 

Maintain duplicates of all the bills and documents submitted to your insurer for future reference. It will also help you maintain records of your transactions.

Remember that your claim may take about 2-3 weeks to be settled. Some insurers may also require you to submit a prognosis by a doctor who suggested the hospitalization to you to ensure it was not voluntary. If you are getting treatment for an accident, you may also be required to submit at FIR.

Additional Read: Pre-existing Diseases Health Insurance: 7 Important Things to Know

Investing in health insurance or a mediclaim policy has become easier than ever as you can do it all online. With many providers offering a range of health policies [3], choose the right one with an easy claim settlement process for your benefit. Consider the individual and family floater health plans on Bajaj Finserv Health to enjoy a wider coverage. Find the right plan for yourself and your family at a reasonable premium and benefit from one of the highest health insurance claim settlement ratios too!

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