Health Insurance: Know how a medical insurance claim is processed

Most of the indemnity products, pay claim up to the treatment expenses after deducting non-medical charges and other deductions as per policy terms and conditions. The claim will be reimbursed by the insurer known as reimbursement claims or customer can opt for cashless facility at designated hospitals.

Procedure for cashless claims
In case the hospital admission is planned, customer should approach insurance desk of the hospital which guides them on cashless facility. The insurance desk forwards case with pre-authorisation application form to insurer. Basis the case details and policy T&C, insurer approves the cashless facility. Generally, this approval should be taken 4-7 days prior to the treatment. Insurer will inform you about the documents that may be required. The customer needs to produce following documents at the network hospital in addition to the documents that are specified by the insurer:-

i. Pre-Authorisation Letter
ii. ID card issued by insurance company
iii. Health Insurance Policy
iv. Aadhar Card, Pan card / Form 60 (For KYC purpose)

After treatment, original bills and treatment evidence should be left with the hospital. The hospital shares these bills with insurer and payment is processed.

In case of any unplanned or emergency medical treatment, the policyholder can contact the insurer through its customer care centre or chatbot facilities to know about empaneled hospitals. At the hospital, the customer can request for cashless hospitalisation by producing the insurance card provided by the insurers along with the policy copy to the insurance desk.

Once the customer makes this request, hospital connects with the insurance company by filing the pre-authorisation request form and consequently the insurer issues an authorisation letter to the hospital. Insurer also shares details pertaining to the policy coverage of the customer. Once the treatment is over, the insurer will settle the payment of admissible claims.

Sometimes the insurer is unable to accept the liability basis the information provided at cashless stage, the customer is asked to put the case for reimbursement.

Reimbursement claims
The insured can download the claim forms from insurer’s website or can be collected from any of the offices/intermediaries of the insurer.

The customer has to provide necessary documents and original medical bills to the insurer at the time of claim filing. These include a claim form, bank details, ID cards, hospital discharge summary, investigation and diagnosis reports and bills, original hospital and pharmacy bills along with paid receipts and prescriptions.For accident hospitalisation, copy of FIR also needs to be shared with the insurer. Insurer evaluates the claim basis the documents after confirming T&C under the policy. Post the evaluation, it makes the payment to beneficiary as per policy terms.

In case of claim repudiation, the insurer provides the grounds on which the claim is non payable.