How to File a Claim Under Your Health Insurance Plan

Health insurance can ease financial stress by paying bills during medical emergencies. But you benefit from it when you know how to file a claim. Whether you use a cashless option or apply for reimbursement, following proper steps can save you from delays or rejections.

This guide breaks down the claim process step by step so you can make the best use of your medical coverage.

Health Insurance Claim Types

Before starting the process, it is important to understand that there are two methods to raise a health insurance claim in India:

1.    Cashless Claim

With a cashless claim, the insured individual can get treated at a hospital listed in the insurer’s network without paying upfront. The insurance company pays the hospital.

2.    Reimbursement Claim

If treatment takes place at a hospital that is not in the network, you cover the expenses first and then submit a claim to the insurer to receive compensation.

The steps for these two claims are different. Let’s look at each of them.

Process for Cashless Claim

Step 1: Find a Network Hospital

Check the insurer’s website or call their customer service to access a list of network hospitals.

Step 2: Present Health Insurance Card

Provide your health insurance card, policy number, and a valid ID at the hospital reception to start the claim procedure.

Step 3: Send Pre-Authorisation Request

The hospital will forward a pre-authorisation request to your insurer. If it’s an emergency, this should be done within 24 hours after admission. To prepare for planned hospitalisation, try to start this process 2 to 3 days ahead.

Step 4: Approval and Treatment Begin

The insurer checks the request. After they approve it, the hospital starts treatment using cashless coverage. You need to handle expenses that are not covered, like administrative fees or consumables.

Step 5: Discharge and Final Settlement

Once the treatment ends, the hospital sends the insurer all the final paperwork for billing. The insurer settles the claim, and the hospital will discharge you.

Reimbursement Claim Process

Step 1: Receive Treatment at Any Hospital

When you get treated at a non-network hospital, you must pay all expenses yourself and keep the original documents.

Step 2: Gather the Necessary Files

Collect key paperwork, including:

• Bills from the hospital and the discharge summary
• Prescriptions and medical test reports

Step 3: Fill and Send the Claim Form

Get the claim form from the insurance company’s website. Complete it and send it with the other required papers to the insurer. Make sure you do this within the deadline, which is 15 to 30 days after discharge.

Step 4: Claim Approval Process

The insurance provider goes through your documents and might ask you to send more if something is missing. Once everything checks out, they deposit the approved claim amount into your bank account.

Quick Tips to Get Your Claim Approved Without Hassle

Let the insurer know right away whether it’s a planned hospital visit or an emergency one. Also, submit all the required documents on time such as:

Documents to Submit

1. Consultation notes from the doctor
2. Your ID proof and a copy of your health insurance policy
3. A cancelled cheque or details of your bank account
4. Always keep several copies of your documents. This is crucial when you’re sending in original ones.
5. Check your policy to see what’s not included. Certain treatments might not fall under coverage.
6. Make sure to submit everything on time. Missing deadlines leads to claims being denied.
7. Double-check that all your details are correct. Even small mistakes, like wrong dates or misspelled names, can slow the process.

Why Claims Get Rejected

Learning why claims don’t go through can help you avoid problems like these:

1. Being hospitalised for conditions not covered in your plan
2. Providing false or altered documents
3. Failing to inform or submit paperwork on time
4. Skipping details about existing health conditions when buying your policy
5. Having a policy that’s expired when treatment occurs

Conclusion

Understanding how to claim health insurance helps avoid a lot of stress during emergencies. Whether you use cashless treatment in a hospital from the network or apply for reimbursement at one outside it, the key steps are simple. Have your documents in order, follow the process, and act.

To choose a reliable insurer, take a look at Chola MS Health Insurance. They offer good medical insurance plans with a wide hospital network and simple claim processes. Their customer-oriented approach, along with easy digital tools, makes handling health insurance and claims easier.

FAQs

Q1. Is it possible to file both cashless and reimbursement claims under one policy?

Yes, you can file both cashless and reimbursement claims under one policy. If you undergo several treatments or hospital stays, with some at network hospitals and others at non-network hospitals, you are allowed to claim under both options within the policy period.

Q2. How much time do I have to submit a reimbursement claim?

Usually, insurers give you around 15 to 30 days after discharge to submit reimbursement claims. Check your policy terms to confirm the exact timeline.

Q3. What happens if my cashless claim gets rejected?

If your cashless claim gets rejected, you can still get treated by paying on your own and later applying to get reimbursed with all the necessary documents.

Q4. Do I need pre-approval to get admitted during an emergency?

Insurers give a 24-hour window to inform them about an emergency admission. It’s a good idea to notify your insurer or TPA as soon as you can.

Q5. Are outpatient (OPD) costs claimable?

Most regular health insurance policies don’t pay for OPD costs unless they are added as a specific feature or extra option. Always check what your plan includes.