Procedure of Health Insurance Claims

A health insurance claim is a request that a health insurance policyholder submits to the Insurance Company to obtain the services covered in their health insurance policy. A health insurance policyholder can either get reimbursed or can opt for a 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.

Types of Health Insurance Claim

Providing healthcare service when needed is the actual utility of a health insurance plan. To ensure timely and easy settlement of all the medical expenses, one needs to initiate the health insurance claim process. There are two ways to claim a health insurance policy:

Cashless Claims

In this type of health insurance claim, the insurer settles all the hospitalization bills with the hospital directly. However, an insured needs to be hospitalized only at a network hospital to reap the benefit of cashless hospitalization. Once an insurer receives intimation from the attendant of the policyholder, the hospital (network) contacts them. The insurer verifies the validity of the policy and policy coverage of that policyholder. Then, a field doctor is assigned to facilitate the request for the pre-authorization document and cross-check the claimed treatment. After verification, a medical team from the insurance company approves the cashless claim for the policyholder as per the terms and conditions of the policy.

Claim Settlement Process for Cashless Claims

The general procedure to avail cashless claim for a health insurance policy is:

• Contact the insurance help desk at the hospital.
• Show the ID card of the insured, provided by the health insurance provider, for identification.
• The hospital will verify the identity of the insured and submit the pre-authorization form to the health insurance provider.
• The insurance provider will review all the submitted documents and process the claim according to the terms and conditions of the health insurance policy.
• Some health insurance providers also assign a field doctor to make the hospitalization process easier for the insured.
• After the completion of all formalities, the claim is settled as per the terms and conditions of the policy.

Reimbursement Claims

In this type of claim process, the policyholder pays for the hospitalization expenses upfront and requests reimbursement by the insurance provider later. One can get reimbursement facilities at both network and non-network hospitals in this case.

Claim Settlement Process for Reimbursement Claims

The general procedure to avail reimbursement claims for a health insurance policy is:

• Contact the insurance help desk at the hospital.
• Show the ID card of the insured, provided by the health insurance provider, for identification.
• The hospital will verify the identity of the insured and will submit the pre-authorization form to the health insurance provider of the insured.
• The insurance provider will review all the submitted documents and process the claim according to the terms and conditions of the health insurance policy.
• Some health insurance providers also assign a field doctor to make the hospitalization process easier for the insured.
• After the completion of all formalities, the claim is settled as per the terms and conditions of the policy.