Health insurance can be one of the best investments you make for both yourself and your family, helping cover medical costs resulting from illness, injury, or accident as well as providing financial security when the unexpected strikes.
Just having health insurance policies isn’t enough to maximize their potential benefits you also must know how to file claims and access those benefits. Filing claims means making requests from insurers for reimbursement of covered medical expenses that you incur as part of the policy coverage.
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India provides various kinds of health insurance policies for individuals, families floaters, senior citizens, groups, critical illness plans, and preventive healthcare plans each one has unique features, benefits, and drawbacks that should help determine which plan best meets the individual’s needs and budget.
This blog post’s primary aim is to offer a step-by-step guide on claiming health insurance in India, whether cashless or reimbursement claims are filed. We will outline each type of claim process along with useful tips and suggestions that ensure an easy claim-filing experience.
But before we dive into the details, let us first understand the difference between cashless and reimbursement claims.
Types of Health Insurance Claims
There are two main types of health insurance claims: cashless and reimbursement.
Cashless Claim
Cashless claims refer to instances in which medical expenses covered by your policy don’t need to come out of pocket for you personally but rather are handled on behalf of the insurer by third-party administrators (TPAs) acting on their behalf. You can take advantage of this facility at any network hospital that works closely with either of them or third-party administrators (TPAs) such as TPA.
Cashless claims offer various advantages, including not needing to arrange funds or submit bills and documents directly to an insurer or TPA for treatment however, their disadvantage lies in following specific procedures or guidelines established by them before receiving care.
A cashless claim is suitable or preferable when you have an emergency situation or a planned treatment that requires hospitalization.
Reimbursement Claim
Reimbursement claims occur when medical expenses that are covered by your policy must be incurred out-of-pocket before submitting all bills and documentation for reimbursement by an insurer. You can utilize this facility at any hospital of your choosing regardless if they belong to a network network hospital network.
Reimbursement claims provide more flexibility and choice when choosing between hospitals and treatments, yet require you to pay out-of-pocket for the initial costs of treatment before collecting bills and documents to submit to the insurer. Submitting bills/documents takes more time.
A reimbursement claim is suitable or preferable when you have a minor ailment or a treatment that does not require hospitalization.
Now that you know the difference between cashless and reimbursement claims, let us see how to file each type of claim in India.
Step-by-Step Procedure for Filing a Cashless Claim
Here are the steps involved in filing a cashless claim:
1. Check your policy coverage and network hospital list: Before seeking treatment, make sure it’s covered under your policy and that there’s an available network hospital near you that offers a cashless facility. You should find this information either in your policy document or the insurer’s website/app.
2. Contact your insurer or TPA and fill out the pre-authorization form: Once you have decided upon a network hospital, contact your insurer or TPA and inform them about your admission details and treatment plan. Filling out a preauthorization form with personal data such as diagnosis details, estimated treatment costs, etc is also required to secure preauthorization approval for admission and treatment.
3. Show your cashless health card and identification details at the hospital: As soon as you arrive at a hospital, present both your cashless health card (issued by your insurer or TPA) and identification details such as an Aadhaar card or PAN card at the admission desk for verification and pre-authorization form submission to insurer/TPA approval.
4. Get the claim approval and settle the deductible amount: Your insurer or TPA will review your pre-authorization form and either approve or decline it based on policy terms and conditions, informing both yourself and the hospital within hours. If approved, an authorization letter will outline their payment for treatment you will still have to cover deductibles, copayments, or nonmedical expenses from the pocket otherwise, they can issue reimbursement claims instead. If rejected, however, all expenses must be covered from personal funds directly either this amount or an amount equalling its full price must be settled through reimbursement claims.
Here are some tips and suggestions to ensure a smooth and hassle-free cashless claim process:
1. Inform your insurer in advance of planned treatments or within 24 hours for emergencies This will help you avoid any delays or rejections in the claim approval process.
2. Keep a copy of all the documents submitted to your insurer or TPA.This will help you in case of any disputes or queries in the future.
3. Follow up with your insurer or TPA regularly until the claim is settled. This will help you track the status of your claim and resolve any issues or queries that may arise.
Step-by-Step Procedure for Filing a Reimbursement Claim
Here are the steps involved in filing a reimbursement claim:
1. Inform your insurer about the hospitalization and treatment details: Once hospitalized or receiving any treatment covered by your policy, inform your insurer immediately by notifying their customer care number, sending them an email, using their website or app, etc. To do this.
2. Collect all the original bills, reports, prescriptions, and discharge cards from the hospital: Once your treatment is over, be sure to collect all original bills, reports, prescriptions, and discharge cards from the hospital in order to file for reimbursement claims and ensure accurate billing reports are filed as well as complete records for review. Afterward, verifying whether all documents provided were accurate is essential as part of this claim process.
3. Fill out the reimbursement claim form and attach all the necessary documents: Next, complete and submit the reimbursement claim form that’s available either through your insurer’s website/app/branch office. Ensure all details are filled accurately while including attachments such as:
- Original bills and receipts
- Original reports and prescriptions
- Discharge card or summary
- Cancelled cheque or bank account details
- KYC documents (such as Aadhaar card, PAN card, etc.)
- Any other document required by your insurer
4. Submit the claim form to your insurer within the prescribed time limit: After filling and attaching all required documents, submit the claim form within its specified timeline (which varies among insurers but usually ranges between 15 to 30 days from discharge). Your form can either be sent online or offline depending on what best meets the insurer’s preferences.
5. Get the claim approval and receive the reimbursement amount after deducting the deductible amount: Your insurer will review and approve or deny your claim according to your policy terms and conditions, communicating their decision within weeks. If approved, reimbursement funds will be transferred directly into your bank account minus any applicable deductible amounts otherwise, they will provide reasons for rejection which you can appeal against if necessary.
Here are some tips and suggestions to ensure a smooth and hassle-free reimbursement claim process:
1. Choose a hospital that provides quality treatment at reasonable costs This will help you reduce your out-of-pocket expenses and increase your chances of getting a full reimbursement.
2. Keep a record of all the expenses incurred during the hospitalization and treatment. This will help you in case of any disputes or queries with your insurer.
3. Verify all the details in the claim form and documents before submission. This will help you avoid any errors or omissions that may lead to rejection or delay in the claim settlement.
4. Co-operate with your insurer during the evaluation process. This will help you resolve any issues or queries that may arise during the claim settlement.
Conclusion
Health insurance can provide your family with financial security during medical emergencies and expenses that arise unexpectedly. Unfortunately, simply having health coverage alone won’t do. To benefit fully from it, it is necessary to understand how you can file claims and access its benefits.
This blog post presents you with an in-depth step-by-step guide for filing health insurance claims in India. We cover both cashless and reimbursement claims and how they differ while offering tips to make this process as smooth and hassle-free as possible.
We hope that this blog post has helped you understand how to claim health insurance in India. If you have any feedback or queries, please feel free to share them in the comments section below. We would love to hear from you.
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