Get Aware of Health Insurance Claim Process

You might have bought the best ‘health insurance plans’ after thorough research, but what if you are in a hospital and you don’t know the appropriate process to file a claim? What if you don’t meet the terms of the plan and your claims get rejected? All that time and money is important that you are investing to buy a foolproof health plan that will come down to zilch if your claims are not filed in order, as per the requirements of the insurance company.

Before we understand the claim process, let’s have a look at the types of claims:

Health Insurance Claim Process, Cashless Claim:

This can be either a planned hospitalization or an emergency. However, the claim process remains the same; the only difference is in the time frame to file the claims. In case of a hospitalization plan, you have to adhere to the following claim process 7 days before admission and in case of an emergency, you have to follow it within 24 hours of getting admitted:

• Inform the insurer of hospitalization.
• Get admitted to a network hospital, show the third-party administrator (TPA) present in the hospital your health insurance plan id card with which they will access your insurance details.
• Based on it, the hospital authorities along with the TPA will fill up a pre-authorization form with the details, medical scans, other required documents, etc., and send it to the insurer for approval.
•  Once the insurer is ok with the documentation and your eligibility for the cashless claim, it will authorize the hospital to proceed with the cashless media claim facility.
•  At the time of discharge, the hospital will send the final bills, complete medical records, and other supporting documents to the insurer for final settlement. After considering deductibles, co-payments, and other exclusions from the insured’s policy, the insurer will settle the remaining claim, and any balance amount will have to be paid by the insured himself.

Health Insurance Claim Process, Reimbursement Claim:

This is where you pay the bills for medical treatment on your own and later file the claims with the insurer for reimbursement. In the case of reimbursements, there can be a claim from a single insurer or there can be multiple claims from multiple insurance providers.

Reimbursement Claim Process from Single Insurer:

• The first step is to inform the insurer immediately at the time of hospitalization.
• After the hospital returns home, you have to fill up the claim form. It is available on every insurance company’s website.
• To ensure you have your health insurance plan claims, make sure that you attach all relevant documents in Original with the claim form. These include medical reports, hospital bills, final discharge summaries, diagnostic tests, etc.
• Be ready for any other documents as required by the insurer. Keep following up with the TPA to keep track of whether they have the documents and whether some more information they need.
• If everything is in order, the claim may approve in 30-40 days or as per the specified turnaround time of the insurer.

Reimbursement Claim Process for Multiple Insurers:

• Inform all the insurers at the time of hospitalization.
• select the company with which you want to file the claim first and fill out the form when you treatment is over
• Attach all documents and required bills with the form in Original and submit them.
• Collect Sign copies of all documents from the hospital that you will submit to other insurers as photocopies are not acceptable as per the terms of the claim.
• Once the insurance company settles your claims as per the terms of your health policy, they will issue a letter that they have the original documents and the claim is
• To get further health insurance plan benefits, attach the above letter with the form and set of documents for the second insurer and submit it to them. Also, mention in a cover letter that you have received X amount from insurer A against your claim.
• If you have any more insurers, repeat the same process as explained above.

Reimbursement for Pre & Post hospitalization Expenses

The decision to buy a health policy can be right but you can make this decision even more successful, you just have to do a little research before buying the policy, otherwise, you will always be searching for better health insurance. These days Pre & Post hospitalization option is presented as a benefit with every health policy, and as far as we are concerned, all insurance companies provide Pre hospitalization within a period of 30 days and Post hospitalization within a period of 60 days. But the thing worth knowing is whether you are getting hospitalization benefits cashless or you will get reimbursement.

If your health policy offers you the facility of cashless hospitalization, then somewhere it will be better for you and in this case, you will have to claim only for other expenses. In addition, If you are going to get reimbursement from the hospital then you will have to claim it along with all the bills.

Getting a Reimbursement Claim is time taking process

Yes, there is no doubt that getting reimbursement after claiming is a time-taking process, first, you claim and after that, you have to add different types of papers and different types of bills and submit them together. If we compare Reimbursement and Cashless service, then we will clearly see that the facility of Cashless Hospitalization is much better and far easier and the best part is that it does not take much time.

But the facility of the cashless hospital is available only in the network hospital of the insurance company, if your insurance company has a network hospital in your city then it is beneficial for you otherwise you will also have to claim and wait for reimbursement. “The whole process takes a maximum of 21 days to settle the reimbursement claim as the insurance company or TPA, verifies the documents, reports, bills, diagnosis reports, etc. If there is any confusion or ambiguity in the bill or report, the insurance company/ TPA sends it back to the policyholder for clarity. If not, the claim will be settled within 21 days.

Do remember that the insurance companies won’t mind clearing the claims in order. Therefore, to enjoy health insurance benefits, read the terms of your policy document carefully, understand the limits mentioned, be aware of the documentation required, and file claims accordingly.

Insurance companies

If you have done everything as per the requirements, your claims will undoubtedly be approved.

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