A health insurance claim is a request submitted by the policyholder to the insurance provider in order to get the services and benefits covered under the health insurance policy. In such a case, the policyholder can get compensation from the insurer through a direct claim settlement option (cashless facility) at the network hospitals or get reimbursed later after paying for the treatment expenses from their own pocket.

It is of utmost importance to understand the health insurance claim process and file a claim within the specified timeline in order to avail of the benefits and perks of a health insurance plan. It is vital to let the insurer know about the claims on time, as it provides the insurer with a window to review and evaluate the claim in order to provide a quick settlement so that you can recover the maximum amount of compensation as early as possible.

Health insurance claim process

It is important to initiate the health insurance claim process as early as possible in order to get a timely and seamless claim settlement. In order to register for a health insurance claim, individuals need to follow the below-mentioned steps:

Cashless claim:

In order to use a cashless claim benefit, the treatment of the insured must be done only at a network hospital of the Third-Party Administrator (TPA) who is servicing your policy. You must get the authorisation for availing of the treatment on a cashless basis as per procedures laid down below and in the prescribed form.

In planned hospitalization, approach the hospital before hospitalization and submit the pre-authorization form and identity proof along with the medical documents.
In an emergency hospitalization, visit the cashless helpdesk at the hospital within 24 hours of hospitalization and submit the pre-authorization form as well as an identity proof along with the medical documents
Once your claim is examined, reviewed, and approved, pay only the deductible expenses at the hospital, and the insurer will settle the rest at the time of discharge.
Reimbursement claim:

A reimbursement claim is where you pay your hospital bills initially and apply for reimbursement later to get the entire amount back. In such cases, you are not mandatorily required to seek medical treatment at a network hospital. Make sure that keep all the required documents such as the claim form, discharge summary, prescriptions and bills ready to submit for a reimbursement claim and follow the process:

Intimate the insurer, then settle the bills at the hospital and collect relevant documents for further process.
Submit the original documents and the claim form within 30 days of discharge from the hospital.
After verification and review of the claim, your claim will be settled by the insurer in few days.

It is essential to understand that all claims are processed subject to Policy terms and conditions. Hence, policyholders are required to read the Policy Wording and Policy schedule carefully.

This article is authored by Ravichandran N, the Chief Technical Officer at Kotak General Insurance, and the views expressed in this article are the author’s personal views.