Introduction: Health Insurance is a Lifesaver But Only If You Know How to Use It
You paid your health insurance premium and have your policy in your hands, and then suddenly you or a loved one needs medical treatment. That’s when many people feel overwhelmed when it’s time to use the insurance.
Where do I look? What documents do I need? Who do I speak to?
Making a health insurance claim can feel like navigating a maze, and when you’re dealing with a health crisis, that’s the last thing you want to deal with. But no need to worry! This article will help you make a claim to your health insurance so that you take out the stress, confusion and delays that you might expect.
It is our objective to provide you with a clear step-by-step map. We have provided examples from real-life experience, and the tips you will find in this guide and hopefully leave you in a better position when trying to make your claims process whether it be for cashless hospitalization or reimbursement.
Step 1: Understand your policy inside and out
Before filing a claim, a good rule of thumb is to ensure that you understand fully what your insurance policy has coverage for. In this manner, you can prevent being taken by surprise later. Check your insurance for the following:
- Hospital network list (for cashless treatment)
- Room rent limits
- Pre and post-hospitalization coverage
- Daycare procedures
- Co-payment or deductible clauses
Step 2: Choose Between Cashless and Reimbursement
There are two ways to claim your insurance:
1. Cashless Claim:
If you go to a network hospital, your insurer pays the bill directly.
You only pay non-covered charges (like food, registration, etc.).
2. Reimbursement Claim:
You’ve gone to a facility that is out of network, you’ve paid the full amount and now submit the claim paperwork to be reimbursed.
It is essential to know your path upfront. Knowing this allows for a smoother admission or discharge process!
Step 3: Inform the Insurance Company
Whether planned or emergency, you must inform the insurance provider at the right time.
For Planned Hospitalization:
Inform 3–5 days in advance.
Share admission details: date, hospital, treatment, and doctor’s name.
For Emergency Admission:
Inform within 24 hours of hospitalization.
Step 4: Submit Pre-Authorization Form for Cashless Treatment
If you want cashless treatment, the hospital’s TPA desk will give you a pre-authorization form.
You’ll need to:
- Fill in personal and policy details
- Attach doctor’s prescription
- Sign and submit to hospital admin/TPA desk
Real Life Example:
Amina in Delhi was appointed for a gallbladder surgery. The hospital filled out the pre-authorization form that day, and within six hours she had a green light from the insurer. She ended up paying only Rs 4,000 for non-covered expenses, out of a Rs. 90,000 bill.
Step 5: Keep All Medical Documents Organized
Even if you’re going for cashless, always collect and keep these:
- Discharge summary
- Prescriptions
- Lab reports
- Medicine bills
- Hospital bills (with GST number)
- Payment receipts (if you pay anything)
- Doctor consultation notes
For reimbursement, you’ll need to submit original documents, so don’t misplace them.
- Pro Tip: Use a simple file folder or scan everything into a Google Drive folder — it saves a lot of stress later.
Step 6: File the Reimbursement Claim (if applicable):
Usually this is anywhere from 7 to 30 days. You need to submit
- Duly filled claim form (download from insurer’s website)
- Hospital discharge summary
- All original bills and prescriptions
- Diagnostic test reports
- Photo ID proof
- Cancelled cheque (for payment)
- Copy of health insurance card
Send this to the insurer’s office or upload via their online portal, if available.
Time to Process: Usually 7–21 days. You’ll get email/SMS updates once it’s approved.
Common Mistakes to Avoid
When you avoid the above mistakes, you will speed up your claim and avoid rejection for cognizable errors:
- Not notifying the insurer within the appropriate time-frame
- Missing documents or sending duplicates
- Getting admitted for conditions that are not covered (e.g. cosmetic surgery)
- Not keeping the original bill for reimbursement
- Providing inaccurate policy number or ID details
What If Your Claim is Denied?
From time to time claims can be denied.Here are steps:
Step 1: Understand why (it is usually in the rejection letter)
Step 2: Obtain additional documentation or clarification from the hospital
Step 3: File an appeal along with a few supporting documents
Step 4: If it is still not resolved, escalate the matter to the Insurance Ombudsman in your locality.
Most authentic claims would get approved if all documentation is done properly.
- Smart Tips to Make Claiming a Little Easier
- Keeping a digital copy of your health insurance policy and ID card
- With all receipts, large or small
- Take a photo of the TPA certificate from the hospital to verify that the hospital is a network hospital.
Conclusion: Be Prepared:
Filing a health insurance claim should be straightforward, prioritized over paperwork, prioritized over health, and prioritized over financial protections.