Reimbursement & Cashless Claims Procedure

What is Covered under Health Insurance Claims?

The insurance company will provide coverage if you are diagnosed with any kind of medical condition, injuries and require medical assistance including surgeries. The insurance company will also cover your stay in the hospital and the price of medicines and other similar items. 

Make sure your condition is not pre-diagnosed before you avail yourself of the health insurance policy, and you don’t seek any kind of cosmetic surgery. In these cases, the insurance company can refuse to provide insurance coverage. 

What is Not Covered under Health Insurance Claims?

Given below are the conditions for which the insurance company may refuse to provide coverage. They are: 

1. Pre-existing illnesses 
2. Cosmetic surgeries 
3. Complications related to infertility or pregnancy 
4. Cost incurred for alternate therapies  
5. Complications due to consumption of drugs, alcohol, or smoking 
6. Health supplements 
7. Diagnostic charges unless part of an on-going treatment 

Eligibility Criteria for Health Insurance Claims

The eligibility criteria to avail a health insurance policy is very simple: 

1. You must be aged between 18 years and 65 years. Some insurers also allow people aged 70 years and above to apply for a health insurance policy. 
2. You must not be diagnosed with any pre-existing illness. 
3. For the claim process, have all your documents in place and inform the insurer about the treatment immediately. 

Documents Required for Health Insurance Claims

The documents you will need to submit during the claim process are given below: 

1. Duly filled claim form 
2. Health Card
3. Consultation papers provided by your doctor
4. Hospital bills including all the receipts stating the payment done by you
5. Diagnosis reports
6. FIR or Medico Legal Certificates if required
7. Payment receipts and invoices provided by the pharmacy during the purchase of medicines and other items
8. Summary of the discharge of the patient 
9. Any other documents as asked for by the insurer 
10. Your health insurance policy documents 

Health Insurance Claim Process

The health insurance claim process is broadly classified as cashless claims and reimbursement claims. It is important to understand the procedure to avoid any delays during emergencies. 

Cashless Claim Process

Step 1: To avail yourself of a cashless claim, you need to get admitted to a network hospital. 

Step 2: At the hospital, you will have to show your health insurance card for identification. 

Step 3: You will receive the pre-authorisation form from the hospital. 

Step 4: You need to fill out the form and submit it at the hospital’s insurance desk. 

Step 5: Once your form is reviewed, it will be forwarded to the insurer by the hospital. 

Step 6: The insurer will review your application form and documents. 

Step 7: After approval, the insurer authorises the claim as per policy terms. 

Step 8: Your insurer directly settles the approved bill with the hospital. 

Reimbursement Claim Process

Step 1: In the reimbursement claim process, you will have to inform your insurer about admission to a non-network hospital. 

Step 2: Once you undergo treatment and settle the hospital bill at discharge, collect all the medical papers, reports, and bills. 

Step 3: Fill out the reimbursement claim form and attach the required documents. 

Step 4: Submit the reimbursement claim form to the insurer. 

Step 5: The insurer will review the claim form and verify the documents. 

Step 6: Once approved, the insurer transfers the claim amount to your bank account. 

Cashless Claim Process for Planned Treatment 

In order to avail the cashless claim facility, the insured has to be treated in an empanelled hospital. 

The claims process for treatment at a cashless network hospital varies according to the type of treatment - Planned or Unplanned. Unplanned medical treatment at a cashless network hospital usually happens in case of an emergency. 

The cashless claims process for planned treatment is as follows: 

1. You must submit the cashless claim form to your insurer by letter or email at least five days before your scheduled treatment. 

1. Once the insurer receives your cashless claim form, they will notify the hospital. 

1. You will then receive a confirmation letter, which remains valid for seven days from the date of issue. 

1. You will have to submit this confirmation letter along with your health card at the time of admission. Your medical expenses will then be settled directly by the insurance company. 

Cashless Claim Process for Emergency Treatment 

The cashless claims process for emergency treatment is as follows: 

1. You must inform your insurance company or third-party administrator within 24 hours of being hospitalised. Once notified, a Claim Intimation or Reference Number will be issued for your case. 

1. The hospital should fill in and submit your cashless claim form to your insurer. 

1. An authorisation will be sent to the hospital by the insurance company on receiving your cashless claim form. 

1. Your medical expenses will be paid by the insurance company. If your claim is rejected, you will receive a notification about the same on your email address and registered mobile number. 

Disclaimer: Premiums may vary depending upon factors like age, location and prevailing taxes/GST. 

How to Claim Reimbursement for Pre- and Post-Hospitalization Expenses

The majority of health insurance policies include coverage for relevant costs incurred before and after hospital discharge as well as for hospitalisation costs. The insurance is required to pay back the costs incurred around 30 days before the hospitalisation and 60 days after release. 

You may add these costs when filing your claim if your whole request is being reimbursed. 

However, if the hospitalisation was cashless, you might need to submit a second reimbursement application. According to the insurance company's terms and rules, the medical bills for the illness for which the insured was hospitalised must be presented.

The insurer will reimburse the appropriate pre- and post-hospitalization costs after verification within a predetermined time frame. 

Reasons for Health Insurance Claim Rejections: 

At times, the health insurance claim gets rejected. Some of the reasons behind claim rejections are given below: 

1. Inaccurate personal details are one of the most common reasons for claim rejection. Any error in personal details, medical history, or policy information can lead to claim rejection. 

1. Not declaring any past illness is another common reason for claim rejection. 

1. Your application will also get rejected if you are rasing a claim of diseases or treatments not covered under your insurance policy. Some conditions, procedures, or hospital charges may be excluded under the policy, leading to non-payment. 

1. At times, claims from hospitals that are not legally registered or do not meet insurer standards may not be accepted. 

1. If your policy is inactive or expired at the time of hospitalisation, the insurer will not pay the claim. 

Ways to Avoid Health Insurance Claim Rejections

Given below are some of the ways through which you can avoid getting your health insurance claims rejected: 

1. Make sure your insurance provider is aware of any existing medical conditions you may have. 
2. Do not forget to notify your insurance provider within the required timeframe of any emergency or planned hospitalisation. 
3. Before filing a claim, make sure to carefully review the inclusions, exclusions, claim filing procedure, waiting periods, and all other features and benefits of your policy. 
4. Send your insurance provider the required documentation in the original form. 
5. Enter a network hospital and take advantage of the cashless claim services there.