How To Claim Health Insurance And What To Do If The Claim Is Rejected?

Health Insurance

It’s wise to be prepared for a sudden medical emergency. A health insurance policy can provide necessary financial support to get medical treatment in time. But medical expenses could burn a hole in your pocket and wipe out your savings. That’s why knowing how to claim health insurance can be of great advantage. Read on to know the correct process to claim your health insurance.

What is Health Insurance Claim?

A health insurance policy takes effect when a policyholder gets hospitalised or faces a medical emergency. At that time, the insured person can make a request to the insurance company to cover their medical costs. This is referred to as making a claim for a health insurance policy. 

How to Claim a Health Insurance?

Insured individuals can either opt for a direct claim settlement (cashless treatment) or get reimbursement for availed health services. In the cashless claims process of health insurance, an insurer pays the claim amount directly to a network hospital. 

A cashless facility is only available when you go to a hospital with which the insurer has prior agreements to offer this facility. Such hospitals are called network or empanelled hospitals.

With a reimbursement facility, you have to pay all medical expenses upfront and request for claim settlement from the health insurance company later. 

How to Apply for a Health Insurance Cashless Claim?

Cashless claims are ideal in situations where you are going through financial instability and do not have access to cash during times of medical crisis. 

Here is a step-by-step guide for you to get a cashless claim with planned hospitalisation:

1. Inform your insurer/TPA about your planned treatment at least 3 to 4 days before hospitalisation.
2. Get a pre-authorisation form from a network hospital or on the TPA’s website. 
3. Fill it up and submit it at the insurer’s/TPA desk in the hospital where you want your treatment.
4. Make sure to carry all required documents to the TPA counter.
5. After approval, the insurer/TPA will send you an authorization letter and inform the hospital about your treatment.
6. On the day of admission, show your health insurance ID card and pre-authorisation letter to get cashless treatment.

Also Read: Understanding Health Insurance Claim Settlement Ratio In India

How to Apply for a Health Insurance Reimbursement?

Insurance companies allow reimbursement claims when an insured person gets treatment from non-network hospitals or when they cannot approve cashless claims. You will need to pay the costs of treatment and medicines from your own pocket and file for reimbursement claims after discharge.

Here are the steps you should follow to make a reimbursement claim:

1. Make sure to safely preserve all prescriptions, medical reports and bills accumulated during your treatment.
2. After discharge, get the discharge certificate or discharge summary from the hospital. 
3. To make claims on medical bills, remember to get them attested and signed by the hospital.
4. Submit all relevant documents in original along with the duly signed claim form to the insurance company.
5. Make sure to file for claims between 7 to 15 days of being discharged from the hospital. 

How to Get Claims Settled in Case of an Emergency?

On many occasions, policyholders need urgent hospitalisation. This can happen in case of an accident of the insured person or a sudden illness that requires urgent hospitalisation. 

Here are the steps to get cashless claims during an emergency:

1. In emergency situations, the family members of the insured have to contact the health insurance provider. 
2. They will have to fill in and submit the pre-authorisation form within 24 hours following hospitalisation.
3. The insurance/TPA desk will send the request across. 
4. The approval should take a few hours. If there is not enough time, you can pay the medical expenses on your own and apply for reimbursement after discharge.

Also Read: Critical Illness Insurance Plans: Do You Need It?

Documents Required to Claim Health Insurance

Most insurance companies require the following documents for the claims process:

• Duly filled claim form
• Copy of the policy bond
• Cancelled cheque
• Health insurance ID card
• Diagnostic reports, including X-ray reports, blood reports etc.
• Consultation papers 
• Pharmacy bills
• Discharge summary
• Valid ID proof of the insured

Note that insurance providers may ask for other relevant documents. 

Health Insurance Claim Rejected: What To Do Next?

Here’s what to do if your health insurance claim gets rejected:

• First, check your insurance claim form thoroughly for mistakes. If there are errors in the information, you can ask the TPA to reopen the case.
• In case a missing document results in your claim rejection, you need to follow up and submit the required document.
• Your insurer can reject a claim for a medical procedure that it considers to be unnecessary. In this case, you can produce a licensed doctor’s opinion to prove your claim.   
• If you have determined that your claim is valid, you can write to your insurer’s grievance cell to challenge the rejection.
• In case your complaint remains unresolved, you can approach the nearest Ombudsman as a last resort. 

Points to Remember while Claiming a Health Insurance

Mentioned below are some critical points that one must keep in mind while filing for a health insurance claim:

• Hospitals providing cashless services
  It is essential to scan through the list of the network hospitals of the insurer from which you can avail of cashless services. Health insurance providers like Navi have a network of 10,000+ hospitals across the country that provide cashless health facilities. 

• Tenure of the insurance plan
  You must remember the validity of your insurance plan and specifically the day it expires so that you can renew it on time. Claims filed on expired insurance policies will not be considered by the insurance company.

• Ailments included and excluded from the plan
  While some ailments are covered in basic health insurance plans, others might not. It is imperative to read the policy documents properly before buying health insurance. It also keeps you aware of all the instances when you won’t be able to file a claim.

• Waiting period for different diseases
  There are a number of pre-existing diseases that are insured by the insurance companies after a certain waiting period. It might range between 2 to 4 years. It is important to know the list of critical ailments that fall under this category in a health insurance plan. 

• Documents for filing claim
  Certain documents should be kept handy when filing a claim for any type of health insurance. Photo identity proof and proof of address, the health insurance card, a copy of the health insurance plan and CKYC for claims that exceed Rs. 1 lakh are required for claiming medical insurance. 

Final Word

Insurance companies offer two methods with regard to the claim process for health insurance policies- cashless and reimbursement. The former provides hassle-free treatment from a network hospital. The latter allows you to get medical treatment from out-of-network hospitals and in cases where cashless claims do not work.

Navi ensures a simple and hassle-free process that gets your claim approved in 20 minutes. You can use the Navi app from Google Play Store to purchase health insurance products from a company with over 10,000 network hospitals across India.

FAQs on How to Claim Health Insurance

Before you go…

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Disclaimer: This article has been prepared on the basis of internal data, publicly available information and other sources believed to be reliable. The information contained in this article is for general purposes only and not a complete disclosure of every material fact. It should not be construed as investment advice to any party. The article does not warrant the completeness or accuracy of the information, and disclaims all liabilities, losses and damages arising out of the use of this information. Readers shall be fully liable/responsible for any decision taken on the basis of this article.