How to Make a Health Insurance Claim: Step-by-Step Process

Health insurance is a contract between a company and an insured entity. Health insurance covers various medical expenses for cashless treatment at network hospitals or reimburses your medical bills. When you buy health insurance, you are required to pay a specific amount, known as a premium. The insured can pay the premium in monthly, quarterly or annual payment. Health insurance proves to be very beneficial in case of medical emergencies.

Table of Content

• Cashless Claim Process
• Reimbursement Claim Process

However, to avail the benefits of the health insurance coverage it is important to understand the process of making a health insurance claim.

A health insurance claim involves submitting a formal request to your health insurance provider to recover the expenses incurred during medical treatment. Primarily, there are two ways to claim health insurance —cashless treatment and reimbursement claim. Here is more about the process for both:

Cashless Claim Process

A cashless claim is a type of claim process where the policyholder does not have to pay for the medical expenses incurred. For this, the individual must seek medical treatment or admission at a hospital that is part of the insurance company's network. The insurance provider directly settles the bill with the hospital in a cashless claim. Here's how you can make a cashless claim for your treatment at a hospital:

• Choose a Network Hospital: The first step is to choose a hospital that is a part of the insurer's network. You can find the list of network hospitals in your medical policy or on the insurer’s website.
• Notify the Health Insurance Provider: Notify your insurance provider about your hospitalisation within 48 hours in an emergency situation, and at least three days in advance for any scheduled procedure.
• Visit the Hospital Insurance Desk: Bring your insurance card and a valid ID and present them at the insurance desk at the hospital.
• Fill out the Pre-Authorisation Form: Get a pre-authorisation form from the third-party administrator's (TPA) desk at the hospital or from your insurance company. Fill out the details and submit the form with ID proof and health e-card to the hospital.
• Wait for the Approval: The insurance company will review your application and may take a few hours to verify your claim. After this, they will directly settle the bill with the hospital.

Things to Keep in Mind

Here are some things to keep in mind when making a health insurance claim:

• Make sure that the chosen hospital is a part of the insurer’s network.
• Ensure that you have all the necessary documents required for submission with the form, like valid ID proof, health e-card, and relevant medical records, for a smooth claim process.

Reimbursement Claim Process

In the event of hospitalisation or incurring medical expenses at a non-network hospital, you will be required to first settle the bills yourself and later submit your health insurance claim with your insurance provider for reimbursement. The insurer will review your claim and reimburse you for the incurred expenses. Here’s a step-by-step guide for the health insurance claim process for reimbursement:

• Notify your Insurance Company: You should reach out to the insurance company within three days of planned procedures. In case of an emergency, you are required to notify the insurer within 24 hours of the procedure.
• Pay the Bills and Collect Relevant Documents: You are responsible for paying the medical bills yourself and ensuring that you retain each bill and invoice. Along with the bills, you should also collect other hospitalisation-related documents, including the discharge summary, hospital bill with detailed cost breakdown, paid receipts, lab and test reports, first consultation letter from the doctor, and an NEFT form.
• Submit the Claim Form: After making the payment for your medical bills, share the required documents with your insurance company and fill out the claim form.
• Await Approval: The insurance company will verify your claim and contact you if they require any additional information or documents. Once the requirements have been fulfilled, the insurance company will settle the claim within a few days.

Things to Keep in Mind

Here are some things to keep in mind when making a health insurance reimbursement claim:

• Maintain a proper document trail of all the bills and receipts and make sure to make copies.
• Ensure that you have all the documents required for making a claim and submit them with the insurer within the stipulated timeframe.

Knowing how to make a claim on your health insurance is crucial. The claim processing steps in healthcare insurance are not difficult or complex as long as you know what to do and are prepared for the same.

At Muthoot Finance, you can buy health insurance with ease. You can explore a range of individual and group health insurance plans, with various coverage options and riders.