Claim process

Cashless Claims Process

If you are opting for a cashless claim, follow these steps:

a. Choose a network hospital: Select a hospital from the insurer's network hospital list.
Ensure the hospital is equipped to provide cashless services.
b. Intimate the insurer: Inform the insurance provider about your hospitalization in
advance, as per the instructions provided in the policy document. This allows them to initiate
the cashless claim process.
c. Submit necessary documents: Provide the hospital with your health insurance policy
details and any other documents required for the cashless claim process, such as your
health card or pre-authorization form.
d. Pre-authorization: The hospital will send a pre-authorization request to the insurance
provider, outlining the estimated treatment costs. The insurer will review the request and
provide approval, subject to policy coverage and terms.
e. Hospitalization and treatment: Once the pre-authorization is approved, you can proceed
with the hospitalization and treatment as per the doctor's recommendations.
f. Claims settlement: After your discharge, the hospital will submit the final bills and medical
reports to the insurer for settlement. The insurance provider will review the documents and
settle the bills directly with the hospital, as per the policy coverage.

Reimbursement Claims Process

If you are opting for a reimbursement claim, follow these steps:
a. Pay for the treatment: Settle the hospital bills and medical expenses directly with the
hospital at the time of discharge.
b. Maintain all necessary documents: Collect all the required documents mentioned in the
documentation requirements section.
c. Claim submission: Fill out the claim form accurately and attach all the supporting
documents, including medical bills, prescriptions, reports, and discharge summary. Submit
the claim form and documents to the insurance provider within the stipulated time frame, as
mentioned in the policy document.
d. Claims review: The insurance provider will review the claim form and supporting
documents to assess the eligibility for reimbursement. They may request additional
information if required.
e. Claim settlement: Once the claim is approved, the insurance provider will initiate the
reimbursement process. The eligible amount will be reimbursed to your bank account or
through a cheque as per the insurer's process.

1) Cashless Claim Process

Cashless, as the name recommends, frees you from the pain of handling cash in bulk. So how do you pay
the bills? As an insurance provider, you become liable to provide your insurance details to the hospital in
order to avail their facilities. It could be with the help of physical proof or even an e-card which is issued
during the mediclaim policy purchase. Based on these proofs only, the hospital accepts your request to
treat you and process the claims accordingly. However, the illness for which you have been admitted
requires that that disease is covered under your insurance plan. After you are discharged from the hospital,
it is the responsibility of the hospital to forward all the bills to the insurance provider.

As soon as these bills are received by the hospital, the bills are scrutinized thoroughly by the respective
departments to understand the nature of the expense, and settle the payment such that all dues are cleared.
This process is known as a cashless settlement where payment instruction flows between the hospital and
the insurance provider. As an insurance holder, you do not have to keep track of the bills physically or
stress about how to pay the medical bills.

But as an insured citizen, how do you go about the claim anyway? Well, there are a couple of methods
which can be kept in mind when you face such a dilemma.

If planned event
Sometimes, doctors inform you prior to the surgery that you would need to undergo one. It could be any
treatment for a matter of fact which needs prior preparation. Under such circumstances, you can always
give your insurance provider heads up at least 4 days prior to seeking treatment at the network hospital.
However, the time frame varies from provider to provider. That is not the end of it. As an insurance holder,
you need to submit a cashless claim form to the provider physically or through electronic media such as
email or fax. The post is also widely accepted in the country, however, slow it might be. As soon as the
insurance agency is informed about the plan, they coordinate the future processes with the hospital and the
insured about the process progress status. All the insurance holder needs to do is provide their health care
at the hospital during admission for the process to get initiated.

What to do if it is an emergency?
Not all illnesses are planned or arrive after informing an individual. Emergencies or casualties comprise a
major fraction of hospital admissions. So, what does one do when they face something unplanned or
unforeseen? The kith and kin of the insured can always contact the customer care of the insurance provider
and inform them of such a case. The customer care representative can find the nearest cashless facility and
recommend it. However, on arrival, it now becomes the prerogative of the hospital to fill up a cashless
claim form and submit it to the insurance provider who would have already informed them of the situation.
The form is analyzed by the healthcare department, and they revert with the details of the coverage of the
health insurance policy to the hospital. All medical bills are taken care of by the insurance company. In
case, the claim is rejected or not processed, the hospital and the insured are informed of the rejection
reason with proper details. Keeping track of the same and following it up to completion until a settlement
is what the insured must ensure after discharge. Hospitals bills have terms and conditions too which need
to be taken care off. The sooner you fix the rejection criteria and process the payment to completion; it
would be an additional burden which would bother you even after your illnesses are cured. It is always
suggested that if you buy an online health insurance plan, keep your close ones informed about the details
such as the mediclaim policy number, policy coverage, customer care center dialing number and the likes
such that they do not have to look around for financial help instead of looking after you.

2) Claim Through Reimbursement Process

This one is a little tricky for the insured since the process demands that they have to claim it from the
service provider after they have been discharged.in simple words, it means that you pay your bills initially
and apply for reimbursement later to get the entire amount back. In such cases, it is not mandatory that the
hospital you seek treatment from, be a network hospital. Walk into any hospital that can treat your ailments
and keep the bills of payment safe. However, you cannot make use of cashless claim process in this case
because it stands null and void.

Provide original bills from the treatment, each one of them, to the insurance company. No insurance
company will support or accept your claim without the original bills. Most of the bills are analyzed and
verified before it is cleared. Often third-party authorizing vendors are hired to ensure that there are no false
claims associated. False claims can refer to fraud bills, manipulated documents, etc. If the claim falters or
is found to be incorrect at any stage of verification, the claim is rejected then and there. Therefore, it is
recommended that you keep the bills intact such that they are legible and do not fail authorization at any
step.

After the claim is verified and found legitimate, the claim is processed easily without any hassles, and the
payment is made to the registered bank account of the insured. However, if the payment is rejected due to
any condition, the insured is notified of the same through customer advising methods. It could be via
email, post or even a call from the claim-processing department.

It is only natural that one might question that if medical bills are enough documentation to claim
reimbursement from the healthcare provider. Of course, you need a certain set of documentation in place
to make the process a success. Any missing document can put your claim progress on hold. Now you do
not want to run pillar to post just because you do not know what document it is! So, we have a
consolidated list which you can follow during the claim process. Even it differs across organizations; you
can always have a follow-up conversation with the agent you purchased your mediclaim policy from to
give you a manual which contains all the details.

The most important documents which are also mandatory are as follows:

 A duly filled and signed claim form. This is the document which can be downloaded online or
obtained from the insurance office.
 Investigation report
 All original bills, receipts, memo, etc. Any bill missing will account for your loss.
 A medical certificate, your case file and other documentation which should be signed by your
doctor. It is more like an attested copy of your illness track record while in the hospital.
 Cash memo for medicines that have been purchased from an external pharmacy.
 Discharge card, summary report and all clearance documents.
 If it was a medical emergency such as an accident or a casualty, an FIR should be deposited. If the
FIR is unavailable, a Medico-Legal Certificate should be mandatorily provided.

After all, documents are duly verified and processed; the claim is deemed to be completed. The final step is
crediting the entire claim amount to the insurer's account which is declared at the time you buy health
insurance.

Usually, third-party administrators are responsible for verifying your documents and claims. As
incentives are higher to limit claims, they take stringent steps to cancel or reject any claim that comes their
way. This is in line with the instructions given by the insurance providers themselves.

Types of Claims in Health Insurance

There are two modes of claims in health insurance - cashless and reimbursement.
1. CASHLESS CLAIM:
This type of health insurance claims process works when you opt for a medical procedure in a
network hospital (i.e., a hospital with which your insurer has a tie-up for cashless
hospitalisations) of your insurance provider. In this case, the insurer will settle your bills
directly with the hospital. Hence, the claim settlement process requires minimum documents
and is quite hassle-free.
2. REIMBURSEMENT CLAIM:
If you choose a non-network hospital for your medical procedure, you must settle the hospital
bills from your pocket and then file a reimbursement claim with the insurance company. For
this, you must submit original bills and receipts from the hospital to the insurance company.
The entire claim settlement process can take around 3-4 weeks.

Steps to File a Cashless Claim in Health Insurance

The following are the steps to file a cashless claim for health insurance.
STEP 1: FIND A NETWORK HOSPITAL
Choose a network hospital for the medical procedure. You can find the list of network
hospitals in the policy documents.
STEP 2: INTIMATE THE INSURANCE COMPANY
If it is a planned procedure, inform the insurance company at least 3 days in advance and get
their approval. For medical emergencies, you must inform the insurer within 24 hours of
hospitalisation.
STEP 3: FILL OUT THE PRE-AUTHORISATION FORM
Obtain the pre-authorisation form from the TPA desk at the hospital or the insurance
company. Fill it out correctly and submit it at the hospital's TPA desk with your ID proof and
health e-card.
STEP 4: CLAIM VERIFICATION
The insurance company will verify the claim and settle your bills directly with the hospital.

Steps to File a Reimbursement Claim in Health Insurance

If you opt for a medical procedure at a non-network hospital, here's how you can file a health
insurance reimbursement claim.
STEP 1: INFORM THE INSURANCE COMPANY

You must inform the insurance company about your hospitalisation at least 3 days in
advance. If it is a medical emergency, inform them within 24 hours of hospitalisation.
STEP 2: OBTAIN THE CLAIM FORM

Collect the claim settlement form from the insurance company or TPA desk at the hospital.
STEP 3: COLLECT THE DOCUMENTS
Once you get discharged from the hospital, settle the medical bills from your pocket and
collect the discharge summary and other bills and receipts from the hospital.
STEP 4: SUBMIT THE CLAIM FORM & DOCUMENTS

Fill out the claim settlement form correctly and submit it to the insurance company along
with the following documents:

• Your health e-card

• Your photo ID proof

• Proof of address

• Original discharge summary

• Doctor's prescription recommending hospitalisation

• Doctor's consultation slip and prescriptions for diagnostic tests

• Certificate from the attending doctor

• Prescription for medicines and original pharmacy bills

• Diagnosis reports of X-rays, blood tests, etc.

• Other original receipts from the hospital

• Breakup of the hospital bill

• Ambulance receipt, if applicable

• FIR, in case of an accident

You must arrange the documents either date-wise or in the prescribed format. Also,
remember to take photocopies of all the documents before submitting them to the insurance
company. The insurance company will also need a cancelled cheque of your bank account for
crediting the proceeds of your reimbursement claim.
STEP 5: CLAIM VERIFICATION AND SETTLEMENT

The insurer will check the claim form and supporting documents before approving your
claim. If everything looks fine, they will approve the claim and transfer the claim amount to
your bank account.

In case of missing documents and incorrect information about age, smoking habit, annual
income, etc., the insurer may reject your claim altogether.
THINGS TO CONSIDER WHILE MAKING HEALTH INSURANCE CLAIMS

The following are some important factors to consider when making health insurance claims.
1. HEALTH INSURANCE VALIDITY:

Check if your health insurance policy is valid. The insurance provider will not entertain your
claim if your health insurance has expired. So, whether you have an individual or family
health insurance policy, make sure the plan is valid before your file a claim.
2. POLICY INCLUSIONS AND EXCLUSIONS:

This is important as you can't file a claim for a condition that is not part of your health plan or
is excluded from it altogether. Even if you file one, the insurance company will reject it. For
example, if you file a claim for a critical illness that is not covered under your critical illness
insurance policy, the insurer will not entertain your claim.
3. WAITING PERIOD:

Before you file a health insurance claim, make sure the initial waiting period is over. Also,
some insurance policies have a longer waiting period for pre-existing conditions, so
remember to check the same before filing a claim.
4. DOCUMENTS REQUIRED:

When filing a health insurance claim, you must submit certain documents supporting your
claim, such as the original discharge summary, hospital bills, doctor's prescriptions, etc.
Check the documents you must submit to your insurance provider and make sure you submit
them all to avoid claim rejection.
5. CLAIM AMOUNT:

If the claim amount is small and affordable, you can choose to pay the same from your pocket
and enjoy no-claim benefits on your healthcare plan.