Health Insurance Claim Process
Health Insurance Claim Process
Health Insurance claims can be made in two ways- the cashless claim process and the reimbursement claim process.
• Cashless claim process- In order to avail the benefits of a cashless claim policy, the insured has to be treated in one of the hospitals that falls under the network of hospitals that the insurance provider has an affiliation with. Upon presentation of the e-card, details of the health insurance policy or any other physical proof of insurance, the insured can avail the benefit of cashless treatment and hospitalization. This facility can be availed only if the injury or illness is covered in the health insurance policy. On discharge of the patient, the medical bills are sent to the insurance provider by the hospital. The company then evaluates the expenses and settles the payment.
• Reimbursement claim process- Health insurance companies also reimburse up to the sum insured, the amount initially paid by the insured in times of illness or accidents. This usually happens in case the patient is hospitalized or gets treated from a hospital that does not fall under the insurer’s network of hospitals. The insured then has to initially pay the cost of treatment entirely from his own pocket and then submit the bills of treatment to the insurance provider for claim settlement. The company then evaluates the cost and then, according to the scope of the policy coverage, reimburses the amount up to the sum insured. In case the treatment is not covered in the policy, the claim is rejected. The following documents need to be submitted during the reimbursement claim process-
○ Duly filled claim form
○ Medical Certificate or form which is signed by the treating doctor.
○ Patient’s Discharge summary or card (original), availed from the hospital.
○ Prescription and cash memos from pharmacies/ the hospital.
○ Bills and receipts (original)
○ Investigation report
○ In case of an accident, the FIR or Medico Legal Certificate (MLC) is also required.
Health Insurance claims can be made in two ways- the cashless claim process and the reimbursement claim process.
• Cashless claim process- In order to avail the benefits of a cashless claim policy, the insured has to be treated in one of the hospitals that falls under the network of hospitals that the insurance provider has an affiliation with. Upon presentation of the e-card, details of the health insurance policy or any other physical proof of insurance, the insured can avail the benefit of cashless treatment and hospitalization. This facility can be availed only if the injury or illness is covered in the health insurance policy. On discharge of the patient, the medical bills are sent to the insurance provider by the hospital. The company then evaluates the expenses and settles the payment.
• Reimbursement claim process- Health insurance companies also reimburse up to the sum insured, the amount initially paid by the insured in times of illness or accidents. This usually happens in case the patient is hospitalized or gets treated from a hospital that does not fall under the insurer’s network of hospitals. The insured then has to initially pay the cost of treatment entirely from his own pocket and then submit the bills of treatment to the insurance provider for claim settlement. The company then evaluates the cost and then, according to the scope of the policy coverage, reimburses the amount up to the sum insured. In case the treatment is not covered in the policy, the claim is rejected. The following documents need to be submitted during the reimbursement claim process-
○ Duly filled claim form
○ Medical Certificate or form which is signed by the treating doctor.
○ Patient’s Discharge summary or card (original), availed from the hospital.
○ Prescription and cash memos from pharmacies/ the hospital.
○ Bills and receipts (original)
○ Investigation report
○ In case of an accident, the FIR or Medico Legal Certificate (MLC) is also required.
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