A Step-By-Step Guide To Navigating Health Insurance Claims

Understanding the complexities of filing a health insurance claim becomes important for financial well-being in this ever-evolving healthcare landscape of India. In this guide, we aim to simplify the claims process so that you can easily and confidently navigate health insurance claims.

What is an Insurance claim?

An insurance claim is a formal request made by an insured individual or entity to an insurance company seeking compensation or coverage for a covered loss or event. When an insured event occurs, such as an accident, illness, injury, or damage to property, the insured party submits a claim to their insurance provider to receive financial assistance or reimbursement as per the terms of their insurance policy.

Assess Your Health Insurance Policy

Before diving into the process of claims, understanding the nuances of your policy is essential. The foundation for an easy claim process is laid by knowing your policy. Know about what is safeguarded under your policy and what isn’t secured. This prevents surprises during the claim process. You must identify the network hospitals that fall under your policy. Choosing a network hospital simplifies the payment process by allowing for a cashless claim process.

Navigating the Documentation Maze

The claims process includes plenty of documentation. Sorting them out efficiently guarantees a problem-free and seamless claims process. Significant reports must be assembled and submitted on time to get your claim approved. The essential documents are as follows:

• 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
• & Many More based on the type of hospitalisation

Choosing between Cashless and Reimbursement Claims

Understanding the distinction between cashless and reimbursement claims is necessary. Both have their benefits, and your decision relies upon the situation.

• Cashless claims: When you are utilising the services of a hospital that falls under the policy network, opt for a cashless claim. The insurer settles bills directly with the hospital, minimising your financial involvement.
• Reimbursement claims: In non-network hospitals or specific situations, reimbursement claims come into play. Pay the bills upfront and later claim the amount from your insurer.

Procedure to File a Cashless Claim

To file a cashless claim, follow the steps below:

• Choose the right network hospital for medical treatment. One can find the network of hospitals within the policy.
• Inform the insurer 3 days ahead of time and get their approval for the claim within 24 hours of hospitalisation in cases of emergencies. Now Insurance companies are trying to approve the claim within 90 minutes too.
• Acquire the pre-authorisation form and fill it out properly. Submit it along with your identity proof and health card.
• The insurance provider will verify the claim and settle the medical bills and costs directly with the hospital.

Process of Filing a Reimbursement Claim

If you decide to get treatment in a hospital that isn’t under the insurer’s network, you should file a claim for reimbursement. Follow the steps below:

Step 1: The initial step is generally to inform the insurer to begin the process of approval of a claim. The insurer ought to be notified 3 days in advance or within 24 hours of hospitalisation during an emergency.

Step 2: Get a hold of the claim settlement form from the insurance agency or the hospital.

Step 3: Settle medical expenses from your pocket and gather the fundamental bills and receipts from the emergency clinic after discharge.

Step 4: Complete the claim form, send the vital records to the insurance provider, and you can start the most common way of documenting a case.

Step 5: Before approval, the insurance provider will completely audit the documents submitted. The claim will be processed and the amount of the claim will be deposited into your account once the submitted documents are approved.

Conclusion

As we draw to a close this guide on how to understand the claims process for health insurance, remember that information is your most important tool. Consistently review and update your knowledge regarding your health insurance policy claims. Remain informed about changes in guidelines and processes to adjust seamlessly to this ever-developing landscape.

Reach out to our specialists by messaging us at support@elephant.in or call us on our help number-1800 266 9693! Visit Elephant.in to get the best health insurance quotes!

*Terms and conditions apply. The information provided in this article is generic in nature and for informational purposes only. It is not a substitute for specific advice in your own circumstances. You are recommended to obtain specific professional advice from before you take any/refrain from any action. Tax benefits are subject to changes in tax laws. Please contact your tax consultant for an exact calculation of your tax liabilities.| EL/BLOGS/23-24/11