What does medical claim procedure & how does it work?

What is Medical Insurance Claim?

A medical insurance claim is a request made by the insured person to the insurance company to pay for eligible medical expenses covered under the policy. A health insurance claim is also called medical insurance claim.

If your claim is approved, the insurance company

• pays the hospital directly through a cashless claim.
• reimburses the medical expenses you have already paid through a reimbursement claim.

The type of claim you can apply for depends on your policy terms, the hospital where you receive treatment, the medical situation, and the claim procedure you choose.

How Does a Medical Insurance Claim Work?

A medical insurance claim process begins when the insured person informs the insurance company about the hospitalization and requests coverage for eligible medical expenses.

Based on your policy terms, the hospital where you receive treatment, and the medical situation, you can make a claim in one of the following ways:

Cashless Claim Process

A cashless claim allows the policyholder to receive treatment at the insurance company's network hospital without paying the eligible hospital expenses upfront.

At the time of admission, the insured only needs to show their health insurance card and a valid identity proof. The hospital sends the claim for approval, and once approved, the insurance company directly settles the eligible medical bills with the hospital as per the policy terms and conditions.

Here's how the cashless claim process works in common hospitalization scenarios.

Scenario 1: Planned Hospitalization

Example: Your doctor recommends a surgery next week.

What you should do:

• Choose a network hospital as mentioned in the insurance document.
• Inform the insurance company or TPA at least 3 days before your planned admission and provide your membership or policy number.
• Fill out the cashless claim request form at the hospital.
• Submit the form along with medical records to the insurance company or TPA.
• The insurance company or TPA will review and verify your documents.
• Once the claim is approved, the insurance company will directly settle the eligible hospital bills with the hospital as per your policy terms and conditions. Expenses such as phone charges, food, attendant charges, and other non-payable items are generally not covered.
• If the cashless claim is not approved, you can file a reimbursement claim.

Scenario 2: Emergency Hospitalization

Example: You are admitted to a network hospital due to an accident or sudden illness.

What you should do:

• In case of an emergency, inform the insurance company or TPA as soon as possible and provide your membership or policy number.
• Fill out the cashless claim request form at the hospital and get it certified by the treating doctor.
• Submit the form along with the medical records to the insurance company or TPA.
• If the cashless claim is approved, the insurance company will directly settle the eligible hospital bills with the hospital.
• If the cashless claim is not approved, you can file a reimbursement claim.

Reimbursement Claim Process

In a reimbursement claim, the insured first pays for the medical treatment and later files a claim with the insurance company for reimbursement.

The insured must submit the hospital bills and other required documents as proof of the expenses incurred during hospitalization and treatment. After verifying the claim and documents, the insurance company reimburses the eligible amount to the insured's registered bank account as per the policy terms and conditions.

Here's how the reimbursement claim process works in common hospitalization scenarios.

Scenario 1: Cashless Facility is Not Available

Example: You are admitted to a network or non-network hospital, but the cashless request cannot be processed or is not available.

What you should do:

• Contact your insurance company through its toll-free number and provide your membership or policy number.
• Pay and settle all the hospital bills.
• Collect and keep all the required documents, including hospital bills, prescriptions, the discharge summary, and other medical records.
• Download and fill out the reimbursement claim form available on the insurance company's website.
• Submit the claim form along with all the medical documents to the insurance company.
• Once the claim is approved, the reimbursement amount will be paid to you. The claim is generally processed within 20 days from the date the insurance company receives all the required documents.

Scenario 2: Claiming Pre-Hospitalization & Post-Hospitalization Expenses

Example: You received cashless treatment for your surgery. Now, you want to claim your eligible pre-hospitalization and post-hospitalization medical expenses through reimbursement.

What should you do?

• Pay the eligible pre-hospitalization and post-hospitalization medical expenses yourself.
• Keep all the original bills, prescriptions, diagnostic reports, and other required medical documents safely.
• Submit a reimbursement claim form and the required documents to the insurance company.
• After verifying the claim and documents, the insurance company reimburses the eligible amount as per your policy terms and conditions.

Important Points to Remember While Filing a Medical Insurance Claim

• Fill out the claim or reimbursement form carefully and provide accurate information. Incorrect or incomplete details may lead to claim rejection.
• Raise your claim request within 7 days of discharge or within the timeline specified in your policy.
• Non-payable items are not reimbursed by the insurance company.
• Keep all your medical bills, prescriptions, discharge summary, and other required documents ready, as the insurance company may ask for them during claim verification.
• Following the correct claim procedure and submitting all the required documents can help make your claim process smooth.

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