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There are two types of Health Insurance Claims in India
- Cashless Claims will be settled by the insurer directly with the hospital. You will have to pay a small portion of the claim, (usually at time of discharge), which are not covered under health insurance plans’benefits, like non-medical expenses.
- Reimbursement claims are health insurance claims, where you pay for the hospitalization expenses upfront and request for reimbursement from the Insurer, after discharge. You can get reimbursement facility at both network and non-network hospitals. You will need to send the bills and other documents (that you get from your hospital at the time of discharge) to your Insurer for reimbursements within 15 days of discharge.
- PRO TIP: It is advisable to find out more information on the insurance company’s claim settlement ratio (CSR) and process – the higher the CSR, the better. It means that the insurer is likely to settle maximum claims out of the total number of claims that are filed with them in a financial year.
Cashless Claims can be of two types
- Planned Hospitalisation is when you are aware of being hospitalised in the near future and you can get a Pre-Authorisation from your insurer before you get hospitalised.
- Emergency Hospitalisation is when the insured meets with an accident or is suffering from an illness that needs immediate hospitalization – an emergency.
Pre & Post Hospitalization Expenses
- Most health insurance plans will pay for your pre & post hospitalisation expenses – Remember to save and retain your consultation and medicine bills. They will also be reimbursed under Pre & Post Hospitalisation expenses as per the process defined by the insurer.
Steps to file Health Insurance Claims
Emergency Cashless Claim
1. Keep Handy patient’s copy of–
- Health card/E-card, that came along with your health insurance plan. (If you have purchased from Sana, Call or send us a WhatsApp at 8278271818 to receive the same now
- Identity Proof -Any government identity card like Aadhaar card, Driving License etc.
- PAN Card - Some hospitals insist on a PAN Card of the policy holder.
2. Approach TPA Helpdesk at Hospital and show them your Health card
3. They will fill a Cashless Form which you may need to sign. Hospital TPA Helpdesk will send the Pre-Authorisation request to respective insurer for Approval. Approvals usually takes anywhere between 30 minutes to 4 hours
Remember to check nearest Network Hospital before admission into a hospital.Click here for Network Hospitals
Your plans may cover Ambulance charges – so check and you can call for an ambulance.
Sana is always there to assist. Please call for any help
Pre-Planned Cashless Admission
- Once your doctor has recommended hospitalisation,contact Insurer or TPA immediately. Call your Insurer on the Tollfree numbers -given on your policy copy. It is good to plan at least 2-3 days before, if not earlier
- Fill up Cashless Pre Authorisation Forms of your Insurer. Click here for Forms Some information on this form will have to be filled in by your doctor and Hospital you plan to get admitted in.
- Fax or Email filled up Form to your Insurer. You can find detail of the same on your policy copy.
Please call for any help - Receive your Pre Authorisation Approval and proceed for admission into the hospital.
Reimbursement Claims:
1. Health Insurance Claims Form of your Insurer filled in all respects and signed by policy holder Click here for Forms
2. Checklist of documents to be attached-
- Original Discharge summary
- Original hospital bill with detailed cost break-up
- Original payment receipts
- Original Pharmacy bills.
- All Lab and test reports
- Copy of Invoice/Stickers/barcode in case of implants
- First consultation letter from doctor
- KYC form
- Filled and signed NEFT form by Policy Holder/proposer
- A blank cancelled cheque copy.
- In case of Accidents, a Medico-Legal-Certificate and/or FIR may also be required
3. Send filled form and documents to Insurer at address provided in your policy copy.
4. Sometimes Insurer may seek additional information or have certain queries, which will need to be answered and sent back for status updates.
Expect health insurance claims reimbursement anytime between 1 week to 1 month.
Some other things to remember
- It may be good to keep a copy of all your documents as you will need to submit Originals
- You may request your hospital, at time of discharge to provide “certified true copy” of all the papers for your records. Duplicate X-Rays and Scans can also be taken upon demand.
- Cross check your Room Rent Limit as per plan benefit with the type and cost of room you are getting admitted into.If you get admitted to a higher cost or category than what your plans allow, health insurance claims may have amount deducted on a pro rata basis on your billed amount which may include other expenses besides your surplus room rent.
To know more about health insurance claims process as defined by Insurance Regulatory and Development Authority of India (IRDAI), you may visit here...
