Health Insurance Claims

A health insurance plan comes into effect when the insured is hospitalised or when the insured faces a medical contingency and incurs cost. At that time, if the hospitalisation or the medical expenses are covered by the health insurance plan, a health insurance claim is said to occur. Under a health insurance claim, the insurance company pays the medical expenses which incur in case of any medical contingency.

Types of health insurance claims

There are two types of claims admissible in a health insurance policy. These are as follows:

  • Cashless
  • Reimbursement

Let’s understand the meaning and the processes involved in both these types of claims.

Cashless claims

Cashless settlement of health insurance claims occurs when the insured seeks treatment in a networked hospital. A networked hospital is one which is tied-up with the insurance company. Since treatments are taken at a networked hospital, the insurance company settles the hospital bills directly with the hospital. You, therefore, do not have to take the burden of paying for the medical expenses yourself.

Here are the steps involved in availing a cashless claim settlement

  • If you are seeking a planned treatment, inform the insurance company beforehand. Intimation should be given at least 3 to 4 days prior to being hospitalised. A pre-authorisation form needs to be filled in and submitted with the insurance company. This form acts as a claim notification. In case of planned hospitalisation, the form should be filled in and submitted 3 to 4 days in advance.
  • If there is a medical emergency and the insured is being hospitalised under an emergency situation, the insurance company should be informed and the pre-authorisation form should be submitted within 24 hours of hospitalisation.
  • Once the pre-authorisation form is submitted, the insurance company assesses the claim based on the form and allows cashless claim settlements.
  • The insured can then avail the required treatments without paying the medical bills incurred.
  • All medical bills, medical reports and other medical documents should be submitted to the insurance company.
  • If there are other expenses which are being covered, original documented proofs of such expenses should also be submitted with the insurance company.

Reimbursement claims

Reimbursement claim happens when the insured pays for the medical bills himself and then gets the expenses reimbursed from the insurance company. Reimbursement claims occur if the insured avail treatments at a non-networked hospital or if the insurance company does not allow cashless claim settlements.

Here are the steps involved in availing reimbursement of your health insurance claims

  • The insured would have to get admitted in a hospital which is not tied-up with the insurance company and avail treatments.
  • All the original medical reports and bills should be retained by the insured. The medical bills should also be paid out of the insured’s own pockets.
  • After being discharged from the hospital, the insured should avail a Discharge Certificate or Discharge Summary from the hospital from which treatment was availed.
  • This Discharge Certificate or Summary should be, then, submitted with the insurance company along with a duly filled in claim form, medical reports and bills in original and other relevant documents which the insurance company requires.
  • The insurance company would, then, analyse the claim, the related documents and the expenses incurred. The expenses would then be reimbursed.

Points to remember

There are certain important points which the insured should be careful about at the time of health insurance claims. These points help in speedy and smooth claim settlement. The points are as follows:

  • Documents required

    Besides the pre-authorisation form and the original medical bills and reports, other important documents would also be required at the time of making a claim. These include the following

    • A valid ID proof of the insured
    • Bills of any equipment used in the operation
    • Copy of the policy bond
    • Cancelled cheque
    • Any other documents as required by the insurance company
  • The sum insured limit

    Health insurance claims are admissible only up to the sum insured limit availed by the insured. If the claim exceeds the sum insured, the excess would have to be paid by the insured. So, the insured should check the sum insured limit of the health insurance policy.

  • Exclusions

    There are some instances which are not covered by health insurance plans. These are called exclusions. If a claim is made for an excluded expense, the claim would be rejected. So, the plan exclusions should be checked before making a claim so that a claim for an excluded expense is not made. Even if the claim is made and subsequently rejected, the insured would know the reason for rejection.

  • Timeline

    There is a timeline for submission of the pre-authorisation form in case of a cashless claim. In case of planned hospitalisation, the pre-authorisation form should be submitted 3-4 days in advance while in case of emergency hospitalisation, the form should be submitted within 24 hours. Compliance of these timelines is necessary to avail cashless claim settlements. If the timelines are not followed, the claim might get delayed.

  • List of networked hospitals

    A cashless settlement of claim is possible only if treatments are availed at a networked hospital. So, if the insured wishes to avail cashless claim service, the list of tied-up hospitals should be checked before seeking treatments. The list is easily available at the insurance company’s website and can be checked online.

  • Validity of the insurance policy

    Health insurance claims are settled only if the health insurance policy is valid and not lapsed. If the policy has been lapsed, the claim would be rejected. So, the insured should ensure that the policy continues without lapse to enjoy easy claim settlements.

How to file a health insurance claim through Turtlemint?

Turtlemint is an online platform which not only allows individuals to buy a health insurance policy easily, it also allows speedy settlement of health insurance claims. Turtlemint has a dedicated claim settlement department which helps customers get settlement of their health insurance claims. To file a claim through Turtlemint, the following steps should be followed:

  • Inform Turtlemint immediately in case of a claim. For planned and emergency hospitalisations, the prescribed timelines should be followed.
  • Turtlemint then informs the insurance company and forwards the pre-authorisation form for approval.
  • Turtlemint co-ordinates and follows-up with the insurance company regarding the status of claim settlement.
  • The insurance company then settles the claim, whether it is cashless or through reimbursement.

Turtlemint, therefore, ensures that all proper documentation regarding the claim is completed and the claim is easily settled by the insurance company. The customer, therefore, is spared the burden of following up with the insurance company at regular intervals.


FAQs

Most insurance companies settle claims in a cashless manner. However, the insured should check the policy document to understand whether the company settles the claims in a cashless manner or through reimbursement. Even in case of cashless claims, treatments must be taken at a networked hospital.


The Discharge Summary and the original medical bills are necessary for getting the medical expenses reimbursed under a reimbursement claim.


A TPA is a Third Party Administrator which facilitates claim settlement between the insurance company and the insured. TPAs are available at the hospital reception desks. They form the point of contact for the customer through which the customer can intimate the claim to the insurance company.


Many insurance companies allow in-house claim settlement. Under this, there is no TPA. The insurance company handles the claims internally. This allows speedy claim settlements.


In case of claim rejection, the insured should find the reason of rejection. If it is a justified reason, the claim would not be paid. However, if the insured believes that the claim is admissible, a complaint can be lodged with the insurance company’s grievance redressal cell.


Yes, a health insurance claim can be settled from multiple insurance companies. All the insurance companies should be informed in case of a claim and the relevant documents should be submitted with each insurer.


If the claim is not intimated to the insurance company within the prescribed timelines, the insurance company would require additional time for claim settlement. This would get the claim delayed. Moreover, the claim might also be rejected if it is intimated after a long time.