What is Medical Insurance Claim Procedure & How Does It Work?

A health insurance claim or a medical insurance claim is a request that is raised by the policyholder for compensation of the expenses incurred for the treatment. The insurance company upon verification of the claim either settles the bills directly with the hospital or reimburses the amount you spend, depending on the type ofclaim procedure you have opted for. 

Types of Health Insurance Claim:

The primary objective of a health insurance policy is to provide financial assistance when required. To get the reimbursement on time from the insurance company, one has to avail either of the two services below:

Cashless Claim –

In a cashless claim, the policyholder can seek treatment from any of the network hospitals of the insurance company. On admission, the policyholder must produce the cashless health card provided by the insurer and the expenses incurred for the treatment will be directly settled by the insurance company; you need not pay a single Rupee. For cashless claim, you only need to show your health insurance card at the time of admission in the hospital. Most insurance companies approve cashless treatment within 4 hours from the time of admission at the network hospital. 

There are two ways to claim for cashless treatment:

Cashless procedure for Planned Admission: 

  • Choose a hospital from the network as mentioned in the insurance document.
  • Inform third-party administrator (TPA) 3 days prior to admission & provide a membership number.
  • Fill cashless request form at the hospital.
  • Submit the form and medical records to TPA.
  • TPA will inspect all the documents.
  • Once approved, the insurance company will settle the hospital bills, which excludes phone charges, attendant charges, food etc.
  • In case of disapproval, one can file for reimbursement 

Cashless procedure for Emergency Admission:

  • In case of emergency admission, inform third party administrator (TPA) & provide a membership number.
  • Fill the cashless format the hospital, certified by a doctor.
  • Send the form along with medical records to TPA.
  • If a cashless facility is sanctioned, hospital bills will be settled directly.
  • Seek reimbursement in case of disapproval 

Reimbursement 

In a reimbursement claim, you must initially pay for the treatment and then file a claim for reimbursement. When you file a claim, you must produce the bills and showcase other records of the money spent on hospitalisation and treatment. The insurance company, after verifying the bills, will credit the amount to your bank account.

In case your request for a cashless claim is rejected, or you or your family member is seeking treatment at non-network hospitals, then you can apply for reimbursement. Remember to start the reimbursement process within seven days of the patient’s discharge. Below is the procedure to begin: 

Reimbursement procedure for a claim:

  • Get in touch with your insurance company through the toll-free number & provide a membership number.
  • Settle all the hospital bills.
  • Present the bills, prescriptions, discharge summary and other necessary documents when you request for reimbursement.
  • Download & fill the reimbursement form, available on the insurance website.
  • Submit the form along with medical records to the insurance company. 
  • A cheque will be disbursed once the claim is approved. The general turnaround time for the process is 20 days from the date of receipt of all documents

Important Points To Remember For Claims:

  • The forms for reimbursement must be filled correctly, if not, then the claim request might be denied.
  • Claim request must be raised within 7 days of discharge.
  • The non-payable items will be not reimbursed by the insurance company.

Follow these steps carefully to get your medical insurance claim approved. Remember to keep all the documents ready as the insurance company may ask for any documents at any time.
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