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Health Insurance Claim

An insurance claim is a formal request by a policyholder to an insurance company for coverage or compensation for a covered loss or policy event. The insurance company validates the claim and, once approved, issues payment to the insured or an approved interested party on behalf of the insured.

A health insurance claim is a bill for health care services that your health care provider turns in to the insurance company for payment.After you've paid, your doctor sends your bill to an insurance claims processing center.

What is Health insurance Claim ?

A health insurance claim is a request that a health insurance policyholder submits to the Insurance Company in order to obtain the services that are covered in their health insurance policy. A health insurance policyholder can either get reimbursed or can opt for direct claim settlement option (also known as cashless treatment) for the availed medical services. In this way, one can either submit the claim form or request the health insurance provider cashless services.
  • How Health Insurance Can be Claim ?
    Health Insurance Policy Can Be Claimed in Two Ways :
    • Cashless Settlement :Every insurance company has network of hospitals that form a part of its PPN (Preferred Provider Network). When you wish to get treated in any of such hospitals, you are entitled for a cashless treatment where the insurance company/Third Party Administrator settles the cost of hospitalization and subsequent expenses directly with the hospital without involving you.
    • Reimbursement of Medical Expenses :In situations, where you are unable to get treated at a network hospital, you can opt for the hospitalization and the subsequent treatment in your choice of hospital, pay for the same through your pocket and then claim for reimbursement. In view of the huge costs involved that you need to bear at the time of discharge from the hospital, this may not appear to be a preferred choice for many.
  • Health Insurance Cashless Claim Can be Classified In two Ways :
    Claims against Planned Hospitalization :
    Cashless claims against planned hospitalization are applicable on medical treatment of diagnosed illnesses. Every insurance company has a list of network hospitals that are authorized to offer cashless benefits to the insured on hospitalization and medical facilities. You can avail cashless facilities by following the below process :
    • Fill up the claim form with details regarding the network hospital where the insured will be hospitalized.
    • Email the form or send it by fax to the insurance company or Third Party Administrator (TPA) for approval of the cashless claim at least 48 to 72 hours before the date of planned hospitalization.
    • After approval, the insurance company or TPA informs the hospital about the approved claim amount.
    • After the completion of treatment at the hospital, the insurance company or TPA directly pays the approved claim amount to the hospital.
    Claims Against Emergency Hospitalization :
    Such claims are applicable for unforeseen emergencies rising due to an accident or a critical illness. In such cases, the insured or his/her family members should follow the below process:Such claims are applicable for unforeseen emergencies rising due to an accident or a critical illness. In such cases, the insured or his/her family members should follow the below process :
    • Intimate the insurance company or TPA within 24 hours of hospitalization and send the filled up claims form by fax or email.
    • After reviewing the form, the insurance company or TPA takes a decision whether to approve or reject the cashless claims request.
    • The decision is communicated to the insured or his/her family member who had intimated them.
    • Types of Health Insurance Claims.
  • How to Claim Health Insurance ?
    For Cashless Settlement: Intimate the insurance company at least 1-2 days in advance in case of planned hospitalization. An intimation should be sent to the insurance company within 24 hours, if it’s an emergency hospitalization. Most network hospitals have a dedicated TPA (Third Party Administrator) helpdesk that assist the insurers with all the necessary documentation and formalities. Hence, it’s significant to contact the TPA desk to fill the claim form and submit the necessary documents like health card, doctor’s report, etc. Once these documents are received by the insurance company/TPA, they are scrutinized to check against the policy coverage and terms. If within the scope of coverage, an approval is sent to the hospital for a specific amount. Should the cost of treatment exceed the approved amount, the hospital can request for the re-approval. If the request for cashless treatment is denied, one can pay towards the hospitalization and treatment from his own pocket and then raise the request for reimbursement.
  • Two Types of Health Insurance Cashless Claim Process :
    • Planned Hospitalization
    • Emergency Hospitalization