A health insurance claim is a request that a health insurance policyholder submits to the Insurance Company in order to obtain the services that are covered in their health insurance policy. A health insurance policyholder can either get reimbursed or can opt for direct claim settlement option (also known as cashless treatment) for the availed medical services. In this way, one can either submit the claim form or request the health insurance provider cashless services.
Providing healthcare service when needed is the true utility of a health insurance plan. To ensure timely and easy settlement of all the medical expenses, one needs to initiate the health insurance claim process. There are two ways to claim a health insurance policy:
In this type of health insurance claim, the insurer settles all the hospitalization bills with the hospital directly. However, an insured needs to be hospitalized only at a network hospital to get the benefit of cashless hospitalization.
In this type of claim process, the policyholder pays for the hospitalization expenses upfront and requests for reimbursement by the insurance provider later. One can get reimbursement facility at both network and non-network hospitals in this case.
As soon as an insurer receives the intimation from the attendant of the policyholder and is contacted by the hospital (network) about the same, the insurer verifies the validity of the policy and policy coverage of that policyholder. Then, a field doctor is assigned to facilitate the request for the pre-authorization document and to cross-check the claimed treatment. After verification, the medical team from the insurance company approves the cashless claim for the policyholder according to the terms and conditions of the policy.
Claim Settlement Process for Cashless Claims
The general procedure to avail cashless claim for a health insurance policy is:
Planned hospitalization comes in picture when the policyholder is aware of the hospitalization beforehand. The steps to claim cashless treatment in this case are:
Generally, an emergency hospitalization is needed when the insured meets with an accident or is suffering from an illness that needs immediate hospitalization.
Note: The toll-free numbers and the numbers on which the fax must be sent are generally mentioned on the policy documents and/or on the insurance ID card of the policy holder.
The general procedure to avail reimbursement claims for a health insurance policy is:
Health Card (Health Insurance ID Card)
All the consultation papers provided by the doctor
Completely filled claim form
All the investigation and diagnosis reports, such as CT scan, X-ray, blood reports, etc.
In the case of an accident, provide the Medico Legal Certificate (MLC) or/and FIR.
Invoices of the pharmacy with respective prescriptions.
Discharge summary
All other relevant documents
Claim Settlement Ratio - FY 2018-2019
| Insurer Name | Claim Settlement Ratio as per Public Disclosure | Effective Ratio |
|---|---|---|
| Religare Health Insurance | 93% | 99% |
| Max Bupa Health Insurance | 96% | 96% |
| Star Health Insurance | 90% | 95% |
| Apollo Munich Health Insurance | 92% | 92% |
| Royal Sundaram Health Insurance | N/A | N/A |
| ManipalCigna Health Insurance | 91% | 91% |
| Aditya Birla Health Insurance | 94% | 97% |
| HDFC Ergo Health Insurance | 97% | 99% |
Note: All the documents, other than the Health Card of the health insurance provider, must be submitted in original.