Everything You Need To Know About Health Insurance Claims

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When it comes to covering medical expenses incurred as a result of a sickness or hospitalization, health insurance comes in handy. Comprehensive health insurance plans cover a variety of charges, including the cost of medications, hospitalization and procedures, and doctor consultations, among others.

Why Should You Get Health Insurance?

The following are some of the most important reasons to purchase health insurance:

Protect yourself against lifestyle diseases: Nowadays, more and more individuals are succumbing to lifestyle diseases including diabetes, obesity, heart disease, pulmonary problems, and so on. While these diseases were once only found in the elderly, they are also affecting the younger population as a result of sedentary lifestyles and rising stress.

Because many of these conditions are chronic, if you are not prepared to deal with the consequences of a probable illness or condition, you may end up spending a lot of money on testing and medicine. A comprehensive health insurance policy will shield you from unexpected costs incurred during routine examinations, as well as assist you with pharmaceutical costs.

Protection for the entire family: Health insurers provide comprehensive plans that cover all of a family’s medical needs. With hyper-personalisation now available, you can choose health plans that cover all of your family’s needs without breaking the bank.

Having a comprehensive family health insurance plan will keep you safe in the event of an accident, while also safeguarding your family and allowing you to provide them with the best possible healthcare.

Protect yourself against medical inflation: Inflation is increasing every day, and it can be seen in all categories of goods and services. The cost of therapy is continuously rising as a result of constant innovation and the introduction of new age drugs to the market.

Everything from consultation fees to prescription costs, hospitalization costs, and ambulance costs are steadily growing, and having a comprehensive health insurance plan will help you keep ahead of the inflation curve. Years from now, you will be able to receive high-quality care without having to worry about rising inflation.

Protecting your savings: If you and your family do not have comprehensive medical coverage and become ill or injured, you may be compelled to use your hard-earned money and savings to obtain effective treatment and medical facilities. In the event of a medical emergency, insurance assures that your money do not go to waste.

What Is The Procedure For Filing A Health Insurance Claim?

The moment of truth for any insurance policy, especially a health insurance coverage, occurs when the claim is filed. The purpose of purchasing a health insurance coverage is to ensure that you are not concerned about the financial expense of treatment in the event of a medical emergency or when seeking medical treatment. It is equally crucial to understand the claims process as it is to acquire an adequate health insurance coverage so that you can rely on your health insurance policy in times of need.

When you make the decision to purchase health insurance, there are a few factors to consider. First and foremost, keep in mind that the plan kicks in when you are hospitalized or have to pay money for medical reasons. The health insurance will only handle your claims if your medical condition is covered by the policy, so check the tiny print carefully. It is preferable to choose a little more expensive plan with better coverage rather than the cheapest option with insufficient coverage.

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There are two sorts of claims that are accepted by health insurance coverage. These are the following:


  • No-cash claims



  • Reimbursements


No-cash claims
The most crucial aspect of cashless claims is that they are simple and quick to process. Most insurance companies have ties with a network of hospitals, and you can use the cashless claim option if you choose a partner hospital for treatment.
You wouldn’t have to pay anything if you filed a cashless claim because the insurance company would settle the claim straight with the hospital. This means you can go to any of the network hospitals for treatment, and the insurance company will pay your bills without you having to pay anything out of pocket.
The Procedure for Filing a Cashless Claim
  • If you need to be admitted to the hospital for a medical procedure, you must first examine the list of network hospitals and then choose one that matches your needs.
  • Once you’ve decided on a hospital, you’ll need to notify your insurance company three to four days ahead of time and fill out a pre-authorization form. This form serves as a claim notification and allows you to make a cashless claim. You have a couple of choices here:
1. Most network hospitals will have a specialized insurance desk in place. This is where you can get the form.
2. You can contact the insurance provider directly via email or a toll-free phone number and request the form from their claims department.
3. Go to the TPA’s (Third Party Administrators) website to download and print the form. The insurance company appoints a third-party administrator (TPA) to handle claim-related procedures on its behalf. The Insurance Regulatory and Development Authority of India must license a TPA (IRDAI).
  • The completed form must be turned in to the hospital’s insurance desk. Once you’ve filed your form, the TPA will review it and send you a sanction letter with the maximum amount that has been approved for your treatment.
  • In the event of a medical emergency, notify the firm and submit the form within 24 hours after being admitted to the hospital. Following receipt of the claim, the company will evaluate it and proceed with the process.
Claims for reimbursement
Under the reimbursement option, you must first pay the bills, and then the insurance provider will reimburse you for the money you spent, according to the original hospital bills, once the claim is processed. This will inevitably be less frictionless than a cashless claim. You do not, however, have to seek medical help solely at a network hospital. You can go to whichever hospital you like.
Steps to Filing a Claim for Reimbursement
All essential documentation should be kept and submitted. The following is a list of the most critical documents you’ll need when completing a reimbursement claim.
1. The claimant’s completed and signed claim form. This form is available for download online or at the insurance company’s office.
2. Your hospital discharge certificate, summary report, case file, and any additional documents pertaining to your treatment. You must have your case doctor at the hospital sign all of these forms.
3. All of your original bills, cash memos, and receipts for prescriptions.
4. You must also send a copy of the First Information Report (FIR) that you filed with the police if the medical treatment you received was as a consequence of an accident. You must supply a Medico-Legal Certificate if a FIR is not available.
Following an evaluation of the documents and in accordance with the policy’s coverage, the insurance company will reimburse you for the expenses incurred during your hospitalization.
Consider These Points When Filing A Health Insurance Claim
Medical emergencies are a huge source of concern, and the stress of the situation may cause you to overlook the claims process. These are some of the things to keep in mind in such instances.
  • You must also present documents such as a valid ID proof, bills of equipment and instruments used during the surgery, a cancelled check, a copy of the policy plan, and any other documents required by the service provider in addition to the pre-authorization form and authentic medical documentation.
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  • Keep in mind that health insurance claims are only valid up to the limit you choose for your sum insured. If your claim exceeds this amount, you will be responsible for the difference. Check the sum insured and select a policy that provides enough coverage.
  • Exemptions to be aware of – Every health insurance coverage may include a few exceptions that you should be aware of. The exemptions will not be covered by insurance, so choose your policy carefully.
  • Remember the claims procedure timetable, as non-compliance can cause delays in processing and prevent you from using the cashless claims option.
  • If you choose for cashless claims, maintain a list of partner hospitals on hand in the event of an emergency.
  • Make sure you renew your health insurance coverage before it expires, because you won’t be able to file a claim if your policy expires.
While there are various factors to consider when purchasing health insurance, it is always better to be safe than sorry. And this is especially true in the post-pandemic era, where we are constantly confronted with new events.
Investing in a health insurance coverage is beneficial to your long-term financial and general well-being because it allows you to save money while also ensuring that you have the finances to take advantage of the best services available. Make certain you select the greatest health insurance package for you and your family.