Frequently Asked Questions claim processes and documents Questions and Answers Related To claim processes and documents

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Health Insurance Claim Assistance

1 What is a Claim notification?

It is an official intimation of a claim situation to an insurer or TPA.

2 When do the claims get denied

In case of fraud or misrepresentation or non disclosure or if claimed medical expenses are not covered within the limits of the policy.

3 Can I avail cashless facility in a non- network hospital?

No, you cannot avail Cashless facility in a Non-Network Hospital. It will be a reimbursement claim settlement for hospitalization in non network hospital

4 Which is a TPA or Third Party Administrators

All registered TPAs are approved by the Insurance regulator IRDAI. Insurers appoint TPAs or have internal teams to administer claims based on their approach to customer service. There are no publicly available measures to compare TPAs.

5 How to claim a reimbursement claim in health insurance?

For reimbursement claims, documents required will include all hospital bills and invoices, discharge summary and reports etc. Required documents are usually listed in the claim process description that you will receive with the policy. It is wise to keep a copy as you may have to submit originals. Now scanned images are also being accepted by some insurers

6 what is Incurred Claim Ratio or ICR ?

The proportion of claims that is paid out against the total amount of premiums received by the insurance company is the Incurred Claim Ratio (ICR). For example, if a particular insurance company pays a total claim of Rs.70 crores in the year, against the premiums received amounting to Rs.100 crores, it would specify that the ICR is 70%.

7 Do I have to pay anything at the time of claims in health insurance ?

There may be Out of pocket cost or expense, which is an expense for medical care that will not be reimbursed by your health insurer.Out of pocket expense includes deductibles, coinsurance, and copayments for services that are covered and also for the expenses of the services that are not covered within your health insurance plan.

8 What is a cashless claim or a cashless facility ?

When you go into the hospitals in the netwrok hospitals list of your insurer, you don’t pay but the insurer pays directly to the hospital upto the pre authorization approved and in line with your policy benefits.

9 Does health insurance pay claim on death

No, Health Insurance does not have a death claim benefit. However if death is from a covered disease, approved medical claims are paid to the nominee.

10 How do i claim cashless facility in my policy ?

You will need to approach the TPA or Insurer's desk when you arrive at the hospital and give your policy details and identity proof. The TPA or Insurer will help you with requesting a cashless claim. Remember to carry your health card that came along with your policy document and any id proof.

11 What is claim settlement Ratio or CSR?

The Claim Settlement Ratio (CSR) is the percentage of claims the insurer has paid out during a financial year. Simple words in the said time period Claims settled or paid divided by Total Claims reported

12 What are the documents required for a claim?

Documents required differ between cashless and reimbursement claims. For cashless, the TPA or insurer's help desks at network hospitals help with the documents required, which can include identity proof and insurance card. For reimbursement claims, documents will include hospital bills and discharge summary. Required documents are usually listed in the claim process description that you will receive with the policy.

13 How can I claim pre & post hospitalization expenses

You can claim pre and post hospitalization expenses by submitting original bill receipts and relevant copies of doctor’s certificate and discharge summary