How to make a health insurance claim

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Published: March 19, 2020 4:05:16 PM

If you are planning for a planned hospitalization, as a policyholder you need to inform the insurer about the forthcoming claim. In the case of emergency hospitalization, the insurer should be informed about the upcoming claim within 24 hours.

health insurance, claim, health insurance claim, claim rejection, health insurance policies, cheaper health insurance, health insurance in India, Cost of Health Insurance in India, UK, USAKeep in mind to retain old health insurance papers, as at times copies of old insurance papers might also be required when making reimbursement claims.

The main aim of a health insurance policy is to provide/settle the claim for the policyholder during hospitalization. Policyholders can make insurance claims either through the cashless mode or reimbursement mode. While some hospitals offer the cashless facility to policyholders (networking hospitals), other hospitals do not offer the cashless hospitalization facility. In such cases, the policyholder needs to pay the dues to the hospital and get the expenses reimbursed by submitting a claim to the insurer.

Here is how to do it:

Inform your insurer – If you are planning for a planned hospitalization, as a policyholder you need to inform the insurer about the forthcoming claim. However, in the case of emergency hospitalization, the insurer or third-party administrator (TPA) should be informed about the upcoming claim within 24 hours.

Documents needed – If it is a not networking hospital, wherein you pay the bills from your own pocket and the insurance company reimburses it later; you need to collect all the documents needed for reimbursement from the hospital. Do so before leaving the hospital, collect all important documents such as the discharge summary, bills, prescriptions, copy of investigation reports, and pharmacy receipts.

Form – To file a claim, the policyholder needs to fill up the prescribed reimbursement claim forms. Note that, some sections of the reimbursement forms also need to be filled by the hospital and signed by the doctor who treated the patient. Hence, get them ready before filing the claim. The claim form can be downloaded from the TPA/insurance company’s website.

Claim Submission – While submitting the claim form, additional documents such as discharge summary, medical bills, a copy of the policy, and investigation reports need to be submitted to the insurer. Note that, the claim must be submitted right after the discharge of the policyholder.

Provide bank details – While submitting the claim form, it is mandatory for the policyholders to submit the policyholder’s bank account details, along with IFSC code. Additionally, a canceled cheque may be required to be submitted by the policyholder so smoother reimbursement of the claim.

Process – On receipt of papers and documents and while scrutiny, the insurance company/TPA might call for additional documents for processing the claim. The policyholder needs to submit those documents to avoid rejection of the claim.

Keep in mind to retain old health insurance papers, as at times copies of old insurance papers might also be required when making reimbursement claims.

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