An insurance claim is a challenging process for many as it involves dealing with the grief of the loss of a loved one or a medical emergency, as well as going through the hassle of umpteen paperwork which has to be submitted physically. However, the insurance premium paid by you becomes worth it when you can sail through the crisis without any financial hurdles. In such situations, an insurer can help in easing the claim process for the bereaved customer. 

In today’s digital world, social media platforms are used for spreading the word about almost everything, whether positive or negative in experience. No insurer would want to be portrayed as having a bad customer experience and therefore, more insurers are focusing on an easy claims process to ensure consumer confidence at all times. One of the ways they try to make it easy is by offering a digital insurance claim.

Types of Health Insurance Claims

There are mainly two kinds of claims in a health insurance policy. These are as follows:

• Cashless
• Reimbursement

Cashless claims - Cashless settlement in health insurance claims involve the insured seeking treatment in a registered or networked hospital. A networked hospital can be defined as one which has a tie-up with the insurance provider. Once treatments are sought at a networked hospital, the insurance provider settles the hospital expenses by directly coordinating with the hospital. The claimant, therefore, does not have to go through the hassle of making medical bill payments out of pocket. 

Here are the steps for availing a cashless claim settlement:

• Customers who are seeking a planned treatment must inform the insurance company in advance. Intimation can be given at least 3 to 4 days in advance of being hospitalised. A pre-authorisation form has to be filled in and furnished to the insurance company. This form can be considered as a claim notification. For planned hospitalisation, the form has to be filled in and furnished 3 to 4 days in advance.
• In case of a medical emergency where the insured has to be hospitalised in an emergency, the insurance provider has to be informed and the pre-authorisation form must be submitted within 24 hours of hospitalisation.
• After the pre-authorisation form is furnished, the insurance company does due diligence of the claim as per the form and permits cashless claim settlements.
• The insured will then be able to avail the required treatments without arranging for payment of medical bills.
• Medical bills, medical reports and related medical documents have to be submitted to the insurance provider.
• For other expenses that are covered, original proofs must be submitted to the insurance company.

Reimbursement claims - Reimbursement claim is when the insured has to pay for the medical expenses himself/herself and get the expenses reimbursed later from the insurance provider. Reimbursement claims are typically made if the insured avails treatments at a non-connected or non-networked hospital or if the insurance provider does not offer a cashless claim facility.

Here are the steps to avail reimbursement of health insurance claims:

• The insured has to be admitted to a hospital which is not a part of the networked hospitals of the insurance company and avail treatment as needed.
• All the original documents like medical reports and expense bills have to be retained by the insured. The medical bills also have to be borne by the insured at the time of availing treatment.
• Once the insured is discharged from the hospital, he/she can avail a Discharge Certificate or Discharge Summary from the hospital about the treatment that was availed.
• This Discharge Certificate or Summary then has to be submitted to the insurance company combined with a duly filled in claim form. The insured also has to furnish originals of medical reports and expense bills and other relevant documents as required.
• The insurance company will analyse the claim, study the related documents and do due diligence of the expenses incurred. Once done, the expenses will be reimbursed.

Additional Reading: How to Get Health Insurance During COVID 19 Pandemic?

Steps to Claim Health Insurance Online

Get Itemized Receipts – For a start, you will have to ask the hospital for an itemized bill. An itemized bill details every service that the medical treatment involved and mentions the cost against each of the services. Ensure that any medication involved in the treatment is listed along with the itemized costs. Your health insurance provider has to attach the original itemized bills while submitting the claim form.

Claim Form – Reach out to your insurance provider for obtaining a health insurance claim form or you can also download a copy from the official website. Your claim form will have additional instructions on all the other information that may be needed from the doctor or healthcare institution. It makes sense to go through it before beginning the claims process.

Make Copies – After you have filled in the claim form and procured the itemized bills from the doctor, make sure to get copies of everything. This will eliminate chances of any errors through the claim process and also make it smoother for you to re-initiate health insurance claims in case any documents are lost. Always check for the billing codes to take out medical errors and reach out to your health provider in case any clarification is needed. 

Review Before Submitting - To ensure that everything is accurate, reach out to your health insurance company and inform them about sending in the health insurance claim form. You can also review all the paperwork with them and ask for any other information that may be required in the process. You can seek clarification with your insurance company about the timelines that you should expect the claims to be settled by. Once everything is in order, you can send the claim form to the insurance company. 

Final Thoughts

Although the health insurance claims in India have not been fully digitised, there is still respite for many claimants as far as online information availability is concerned. Claimants can easily carry out some of the initial steps like downloading of form, reading through instructions, etc online.