Health Insurance Claim Process: Simplifying Your Coverage

Health insurance serves as an asset in times of medical emergencies. However, just purchasing a policy is not enough. You must understand how to access insurance money in case of medical emergencies and treatments. For this, you must familiarize yourself with the medical insurance claims processing steps.

Being unaware of the nitty-gritty of the health insurance claim process can make it difficult to get the claim money when needed, creating stress and panic during a medical emergency.

But worry not. In this article, we’ll guide you through the healthcare claims processing steps to ensure a hassle-free experience.

How to file a health insurance claim? 

You can file a claim for your medical expenses in two ways:

–Cashless claim: It allows you to receive medical care at a network hospital without making any upfront payment. Depending on your policy terms and coverage, the insurer will directly coordinate with the hospital to settle the bill.

–Reimbursement claim: This typically applies when you receive medical treatment at a hospital not a part of the insurer’s network. In this case, you have to pay for the expenses yourself and seek reimbursement from the insurer.

Step-by-step procedure for filing a reimbursement health insurance claim 

When you visit a non-network hospital of your insurer, you can opt for a reimbursement claim. Here, you pay the bills first and then get reimbursed by the insurance provider.

A reimbursement claim functions as a backup for cashless claims. Follow this step-by-step guide to make a reimbursement claim for your medical expenses:

Step 1: Inform the insurer

Even if you intend to file a reimbursement claim after the treatment, you must notify your health insurance provider as soon as the treatment begins at the non-network hospital.

Step 2: Apply for a reimbursement claim

Collect and fill out the reimbursement claim form for the application process. You can get it at the hospital’s insurance desk or submit an online form if the insurer offers the facility.

Step 3: Collect the necessary documents

Along with the claim form, you will also have to submit documents like original bills and receipts of hospital and medicines, hospital discharge card, policy copy or insurance card, reports of tests conducted during, pre, and post-hospitalisation, Medical Certificate and prescriptions signed by the doctor, etc.

Make sure you have the complete list of documents required in one place.

Step 4: Submit the documents

Submit the claim form along with all the documents online or offline. After receiving the documents, the insurer/TPA will verify them and reimburse the funds to your account.

Step-by-step process for filing a cashless health insurance claim

With the cashless claim facility, you can get medical treatment at any network hospital without worrying about the funds. Here’s how:

Step 1: Know about your policy

Carefully read the inclusions and exclusions of your health insurance policy to clarify what is covered and what is not.

For instance, some insurers do not cover pre-existing diseases. For example, if you had diabetes before purchasing the policy and made a claim for diabetes treatment costs, the claim would be rejected.

Thus, knowing the exclusions and inclusions will help avoid claim rejection and confusion.

Step 2: Know the list of network hospitals

The second step is to be aware of the network hospitals of your insurer. You must visit a network hospital to receive medical treatment via a cashless claim. Show your health insurance card to get admitted and receive treatment. Your insurance provider will directly settle the bills with the hospital. Since the cashless claim facility is only available for network hospitals, you must select an insurer with a wide network.

Step 3: Inform your insurer

Before getting admitted to the network hospital or starting treatment, inform the insurer about the procedure. You can do this through a dedicated helpline number or by filling out the pre-authorization form.

Step 4: Fill out the pre-authorisation form

Collect the pre-authorisation form from the hospital to proceed with your cashless claim. The TPA/insurer will help you fill it out. Here, while you are not required to submit documents like hospital bills or prescriptions, you will have to present your cashless health card and identification proof.

Step 5: Submit the form

After filling out the form, submit it to the insurance desk. The TPA will then process your application and send you a confirmation email. It will also send a letter authorising the maximum treatment cost.

Key considerations to keep in mind while claiming your health insurance

When it comes to the hospital insurance claim process, there are a few things that you must keep in mind to make informed decisions. These include:

#1 The sum insured limit

Based on your policy, you can only seek coverage up to a certain amount from your health insurance. If your medical bills exceed this limit, you will have to bear the additional expenses.

Thus, when filing your health insurance claim, check the sum insured limit in advance to avoid any confusion.

#2 Timeline

There are specific timelines that you must follow to get your claim.

In the case of a cashless claim, there is a deadline for submitting the pre-authorisation form, which is typically 3-4 days before the treatment for a planned hospital visit. In the case of emergency hospitalisation, the deadline is 24 hours post-hospitalisation. If you don’t meet the deadlines, your claim can be postponed.

#3 Validity of the policy

You can only make a claim if your health insurance policy is active. Therefore, make sure to check its validity to experience an easy, unrestricted health insurance claim procedure. You can contact the insurer’s customer care and give them your policy details to check its status.

Wrapping up

Health insurance helps you deal with hefty expenses comfortably in times of medical emergencies. But you must be well-versed with the medical insurance claims processing steps to reap the benefits of your policy.

You must also carefully select the right insurer that provides 24/7 customer service and will guide you through the process.

This is what we at Tata Capital do. We help you file a claim online and guide you through the process to ensure a seamless experience.