What Is The Process To Claim In Health Insurance?


When you buy health insurance, reimbursement or cashless claim processes are available from your insurer. The importance of the claim procedure is not be underestimated when it comes to comparing various health insurance plans and their providers. Whether you are comparing mediclaim vs health insurance, or are looking to buy a family floater plan, understanding the claim process is an important step to go through before you buy. Here’s a guide on the same.

Cashless claim process:

As the name implies, cashless eliminates the hassle of handling large amounts of cash. To use the network hospital’s services, you must provide your health insurance plan information. It could be via physical proof or an e-card from the mediclaim policy transaction.

How to handle an emergency?

Not all diseases are planned or announced. Emergencies or casualties account for most hospital admissions. What happens when something unexpected happens? In such a circumstance, the insured’s family can contact the insurance provider’s customer service. The customer support representative can recommend the nearest cashless facility.

On arrival, the hospital fills in a cashless claim form and submits it to the insurance provider, who has been informed of the circumstances. The hospital receives health insurance coverage details from the healthcare department after they review the paperwork. The insurance company pays the medical bills up to the limit.

Reimbursement process:

In case of reimbursement, after being discharged, the insured must claim the bills paid from the insurance provider. Simply put, you pay your bills and then request reimbursement to get the full money back. You don’t have to go to a network hospital in such instances. Visit any hospital that can treat you and keep your bills safe. However, the cashless claim method is invalid in this scenario.

Provide each treatment bill to the insurance company. Your insurance company will only pay with the actual bills. Before clearing, most bills are scrutinised and validated. Fraud bills, falsified paperwork, etc., are false assertions. At any verification point, the claim is denied.

After verification, the health insurance claim is processed quickly and paid to the insured’s bank account. The insured is alerted via customer advising if the payment is denied—email, mail, or phone from the claim-processing department.

One can wonder if medical bills are enough to obtain compensation from the healthcare provider. Naturally, you need specific documentation to succeed. Your claim may be halted by missing documents.

Required documents include:

  • A completed, signed claim form. The health insurance plan agency or the insurer’s website can provide this document.
  • Investigation findings
  • All original bills, receipts, memos, etc.
  • A doctor-signed medical certificate, case file, and other documents. It’s like an attested copy of your hospital illness record.
  • Cash memo for external pharmacy-purchased drugs.
  • Discharge card, summary report, and all clearing documents.

If it was a medical emergency like an accident or casualty, file a FIR. If the FIR is missing, a medico-legal certificate is required. The claim is complete after the documents are checked and processed. The final step is crediting the claim amount to the insurer’s account.

Please note that these processes are carried out in accordance with insurer’s guidelines.

‘Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.‘

*All savings are provided by the insurer as per the IRDAI approved insurance plan. Standard T&C apply