The A-Z of Health Insurance Claims - when and how to raise claims for medical expenses in your policy

The true benefit of health insurance is experienced when a medical expense arises on account of hospitalization or treatment for a health contingency. Arranging urgent funds on your own during such sensitive times becomes a harrowing task. In such a difficult situation having a comprehensive health insurance policy eases the financial burden and the hassle of organizing cash to a great extent.

The health insurer settles the medical claim incurred by the insured person for diseases and treatments as per the health insurance plan specifics. Here are the important aspects of health insurance claims:

1. Types of Health Insurance Claims that are Settled by Insurance Companies:
   1. Cashless Claim: A cashless settlement of a health insurance claim occurs when the insured member undergoes hospitalization or treatment in a network hospital associated with the insurance company. Here, the insurer directly settles the bills with the hospital and the insured member need not pay for the same.
   2. Reimbursement: A reimbursement of a health insurance claim occurs when the insured member undergoes hospitalization or treatment in a non-network hospital i.e. a hospital that is not associated with the insurance company. Here, the insured member pays for hospitalization or treatment cost on his or her own, and later gets the expenses reimbursed by the insurer.
2. When can you Raise Medical Claims:
   1. If the Type of Medical Expense is Covered: I.e. whether for pre-, in-patient or post-hospitalization, day-care procedure, OPD expense, alternate treatment (AYUSH) etc. Most Health Insurance plans offer a combination of these coverages, which means that it is not standard for all health insurance plans to cover all these expenses. So, a medical claim can be raised only for an expense head that is covered by your plan.
   2. If the Condition is Included in the Plan: Health insurance plans take care of expenses incurred due to an accident or a life-saving surgery, even for vector borne diseases and contagious diseases like Covid-19. More importantly, they explicitly mention the list of medical conditions, illnesses or diseases that are not covered under the plan. A Covid-19 medical claim cannot be raised for excluded conditions, ailments or procedures.
   3. When Waiting Period has been Served: Aside from the initial waiting period of 30 days (except in the case of accidents), medical claims can be raised only for those conditions and treatments that have met the waiting period requirement. For example, Pre-existing Disease Waiting Period, Specific Disease Waiting Period, Maternity Waiting Period etc.
   4. When all Pre-existing or New Medical Conditions have been Fully Disclosed: At the time of applying for a health insurance policy, or enhancing the sum insured under an existing policy, it is imperative that previous, ongoing and newly diagnosed medical conditions or diseases are disclosed to the insurer for transparency. Should that not be the case, the insurance company is likely to reject or decline the claim on grounds of non-disclosure.
   5. When Correct and Up-to-date Information is Shared: Insurance companies collect personal identity information of all insured members at the time of policy application, and request insured members to intimate in case of any revisions. So, it is important that all the details such as full name, date of birth, communication address (all as per official records) and other requisite information is correctly updated in the insurance company’s database. Only when these details are matched against the corresponding document (as proof) will the insurance company accept the medical claim.
      
      NOTE: All the above points are explicitly mentioned in the health insurance plan terms and conditions document along with all other related specifics. It is imperative that the Policy Wordings or Customer Information Sheet be examined thoroughly for complete knowledge on all the aspects of permitted coverage. If any of these points are unfulfilled, the medical claim is likely to get rejected (meaning settled for a lesser-than-claimed amount) or declined (meaning denied for settlement).
3. How to Raise a Medical Claim:
   1. Procedure or Process to Raise Medical Claim:
      A medical claim can be raised with any of the following entities:
      1. Directly with the Insurance Company: Insurers have a pre-defined process for raising medical claims. Some insist on online submission, while others demand that the documents be dispatched physically.
      2. Via TPA: Some insurance companies have Third Party Administrators (TPAs) who facilitate claims management on their behalf with the insured member.
      3. Via Insurance Broker: Registered and reputable insurance brokers assist with claims handholding. SANA.Insure has a dedicated team of Relationship Managers who directly coordinate with the insurance company or TPA for hassle-free and swift claims settlement.
         
         For Planned Treatment: If you have to undergo a procedure or treatment that is pre-planned under doctor’s advice, you will need to inform the insurance company prior to the scheduled date (normally 4-5 days in advance. The timelines are insurer-specific). In such cases, a Pre-Authorization Form needs to be submitted for approval to the insurance company, so as to enable cashless claim settlement.
         
         For Medical Emergency: In an unforeseen medical exigency, the insurance company can be contacted by the network hospital where the insured member is admitted. If the emergency treatment is being availed at a non-network hospital, then the call needs to be arranged personally. Here, too, a Pre-Authorization Form needs to be submitted at the earliest.
         
         Claim Submission Timelines: The claims process along with submission timelines are specific to the insurance company.
         
   2. Paperwork to be Submitted for Medical Claims:
      
      1. Insurer Claim Form
      2. Insurer Pre-Authorization Form
      3. Medical Records (Diagnostic Tests, Lab Reports, Doctor’s Prescription etc.)
      4. Hospital Discharge Sheet
      5. Hospital or Clinic Invoice
      6. Policy Copy and/or Number
      7. Valid ID Proof
      8. Other Documents (which the insurer might seek over and above the other standard documents)
         
         NOTE: It is important to know these details beforehand from the insurer who has issued the health insurance policy, as the list of documents required and the procedure to raise claims differ between insurers. Typically, this information is available on the insurance company’s website.
4. Some Important Policy Features that Impact Claim Amount:
   1. Sum Insured
   2. Indemnity or Fixed Benefit
   3. Deductible
   4. Sub-limits
   5. Co-payment
   6. Exclusions
   7. Policy Expiry Date

You can learn more about claims management by visiting our web page Health Insurance Claims

If you already have a health insurance policy and are seeking assistance with claims management, we at SANA.Insure will be glad to be of help! Please click on Contact us and register your requirement with us. A Health Insurance Expert will contact you soon.

We invite you to visit our health insurance portal, SANA.insure for quick, unbiased, simple and easy access to comparative information on over a hundred health policies available in India, suited to your needs. You can also get in touch with us over WhatsApp chat on 8278271818 or call us on 1800 202 8118 to connect with a Health Insurance Expert at SANA.Insure.

Wish you a healthy and happy life!