Health Insurance claim, types and its process: Nation learns

By | July 17, 2020

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.


  1. Cashless Claims
  2. Reimbursement Claims

Process of 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. The insurance company settles the hospital bills directly with the hospital. Therefore insurer will be burden free from paying medical expenses.

Here are the steps involved in availing a cashless claim settlement

  • 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, the insurance company should be informed and the pre-authorisation form should be submitted within 24 hours of hospitalisation.
  • Then 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 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 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.

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