Health Insurance Claims Process Is A Nightmare: Busting Five Common Myths

Busting these myths and more with our frequently asked questions about the health insurance claim process

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We are back with another set of frequently asked questions about health insurance. This time we will be focusing on one area — the claims process. Read on as we run through some of the most common queries related to this procedure to ensure that you have clarity on all things claims related.

How do I make a health insurance claim?

The health insurance claim process has become easier over time. However, one needs to keep in mind that the claim process depends on the type of hospital you choose for your treatment. If you visit a network hospital, the claim process is quite simple. Just inform your health insurance company or third party administrator (TPA) appointed by your insurance company, provide your insurance details to the hospital and that’s it! You won’t have to pay any bills (except non payables and deductibles); the insurance company will coordinate with the hospital directly and settle all your dues for you.

If you do not visit a network hospital for your treatment, you will have to pay the bills on your own and then submit a claim to get your expenses reimbursed. After being discharged, you need to collect all the bills and submit them along with the duly-filled claim form. The insurance company will evaluate your documents and reimburse as per the terms and conditions of your insurance policy.

Is there a time limit to register a claim?

Yes, one must inform the insurance company within 24 hours of being admitted. In case of a claim for reimbursement, you may submit the claim form within 30 days of being discharged from the hospital.

Can my claim be rejected?

It’s highly unlikely, but yes, health insurance claims can be rejected. The claim may be rejected if it is found that you’ve hidden details from your insurance provider. A claim might also be rejected if it is found that hospitalisation is not necessary for your condition or hospitalisation is for a condition which is an exclusion as per policy terms and conditions

Is there anything I can do if my claim is rejected?

Yes, but this depends on the reason due to which the claim was rejected. If you have not submitted complete information which you think can assist you in the claim process, you may submit it to your health insurance company.

What are the documents required?

In case of a cashless claim, documentation is almost non-existent. After informing your insurance company and providing your health card to the hospital, you and the hospital will be provided with an authorisation letter. For reimbursement, on the other hand, you will require the following documents (tentative list):

  • Duly-filled and signed claim form
  • Doctor’s consultation report with prescription for medicines and investigations
  • Investigation reports such as X-rays/scan/ECG, lab reports
  • Original medical bills from hospital, doctors, pharmacies or diagnostic centres
  • Original discharge card
  • Copy of FIR (in case of accident)
  • Cancelled cheque
  • Photocopy of health card of patient and PAN card of insured

We hope that you never have to make a claim, but in case you do, we hope these answers make things easier for you.

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