Health Insurance Claim Process in India: A Step-by-Step Breakdown

Health insurance helps protect against unexpected medical costs, but the claim process in India can feel overwhelming especially during emergencies. This guide simplifies the steps, documents needed, and tips for filing a successful claim.

Types of Health Insurance Claims in India

There are two primary types of health insurance claims in India, cashless claims and reimbursement claims. Each type has its own process, and the way you file the claim depends on the type of treatment and the hospital you choose.

Cashless Claims

Cashless claims are the most convenient option, where the insurer settles the medical expenses directly with the hospital, without the need for the policyholder to pay upfront. This service is available at network hospitals that have tie-ups with your insurance provider.

• Eligibility: The hospital should be part of the insurance company’s network.

• Payment: The insurer directly settles the amount with the hospital, leaving the policyholder to pay only the non-covered expenses, such as the co-payment portion or unapproved charges.
  

Reimbursement Claims

In reimbursement claims, the policyholder pays the medical expenses upfront and later submits the bills to the insurance company for reimbursement. The insurer then assesses the claim and reimburses the amount as per the policy’s terms.

• Eligibility: This is available for both network and non-network hospitals.

• Payment: You pay the medical bills and later submit the claim for reimbursement, which can take some time to process.
  

Steps to File a Health Insurance Claim

Here’s a step-by-step guide to help you through the health insurance claim process when you’re opting for a cashless or reimbursement claim.

Cashless Claim Process

A cashless claim allows you to receive treatment at a network hospital without paying upfront. The insurer settles the bill directly with the hospital. Here’s how to go about it:

• Select a network hospital from your insurer’s list.

• Inform your insurer about the hospitalisation—within 48 hours for emergencies or at least 3 days before a planned procedure.

• Visit the hospital’s insurance desk with your health card and a valid ID.

• Submit the pre-authorisation form along with your documents to the TPA desk.

• Wait for approval from the insurer. Once approved, the insurer pays the hospital directly.

Note: Always confirm that the hospital is in-network and keep all your documents ready for a smoother process.

Reimbursement Claim Process

If you’re treated at a non-network hospital, you’ll need to pay the bills first and claim reimbursement later. Here are the steps:

• Notify the insurer—within 3 days for planned procedures or within 24 hours in emergencies.

• Settle the hospital bills yourself and collect all related documents: discharge summary, invoices, test reports, prescriptions, and payment receipts.

• Submit the filled claim form and required documents to the insurer, including a copy of your ID and bank details (via NEFT form).

• Await verification and settlement. The insurer will review your claim and reimburse the approved amount.

Note: Keep a copy of all documents and submit the claim within the insurer’s specified timeline to avoid delays.

Key Documents Required for Health Insurance Claims

Here’s a list of common documents required for both cashless and reimbursement claims:

Discharge Summary:

This document is issued by the hospital when you are discharged. It contains important details about your treatment, including diagnosis, treatment received, and medical history.

Hospital Bills:

Detailed hospital bills that include charges for room rent, doctor’s fees, surgery costs, medication, and diagnostic tests.

Prescription and Medical Reports:

These documents include prescriptions, diagnostic reports, and other medical certificates that provide proof of your treatment.

Claim Form:

The form provided by the insurer that needs to be filled out and submitted.

KYC Documents:

Government-issued identification documents, such as your Aadhar card or PAN card, to verify your identity.

Policy Copy:

A copy of your health insurance policy for reference.

Tips for a Smooth Health Insurance Claim Process

Here are a few tips to ensure your health insurance claim process is smooth and hassle-free:

Keep Your Documents Ready

Ensure that all your documents, including the claim form, medical reports, and hospital bills, are in order before you submit the claim. Missing documents or incomplete forms can delay the approval process.

Choose a Network Hospital

Opting for a network hospital that has a tie-up with your insurer can simplify the cashless claim process, as the hospital will directly communicate with the insurer to settle the claim.

Check Your Coverage

Before undergoing treatment, it’s a good idea to check your health insurance policy to ensure that the treatment is covered. This can save you time and effort in the claims process.

Timely Claim Filing

Ensure that you file your claim as soon as possible. Health insurance policies typically require you to file claims within a specific time frame. Delays can result in claim rejection.

Stay in Touch with Your Insurer

If you have any doubts or concerns during the claims process, stay in touch with your insurance company. Regular follow-ups can help ensure that your claim is processed efficiently.

Conclusion

The health insurance claim process in India could be made simple if you follow the steps and keep your documents ready. Choosing a plan with clear coverage and an easy claim process ensures better protection against rising healthcare costs. You can explore such hassle-free health insurance plans on Bajaj Markets, making the entire process more convenient and transparent.