⚡ Quick Summary: Mastering Health Claims
A medical emergency is stressful enough without the added burden of fighting with your insurance company. Understanding the Health Insurance Claim Process in advance can save you lakhs of rupees and prevent rejection. In India, claims are settled in two ways: Cashless and Reimbursement.
Cashless Claims are the most convenient but require strict timing. You can only avail of this at "Network Hospitals" tied up with your insurer. For planned surgeries (like Cataract or Hernia), you must inform the insurance company (TPA) at least 48 hours in advance to get pre-authorization. For emergencies (like accidents or heart attacks), you must intimate them within 24 hours of admission. The hospital's insurance desk handles the paperwork, and the insurer pays the hospital directly.
Reimbursement Claims happen when you go to a non-network hospital. Here, you must pay the full bill from your pocket first. After discharge, you have 15-30 days to submit original documents—including the Discharge Summary, Final Bill with Breakup, Lab Reports, and Pharmacy Receipts—to the TPA. A common reason for partial rejection is "Non-Medical Expenses" (consumables like gloves, masks, admission charges), which are usually not covered unless you have a specific rider. This guide walks you through the exact documents needed to ensure 100% settlement.
How to File a Health Insurance Claim (Cashless & Reimbursement)
A medical emergency is stressful enough; filing a claim shouldn't be. Whether you are at a Network Hospital (Cashless) or Non-Network Hospital (Reimbursement), this guide will ensure your claim gets approved 100%.
Warning: The "24-Hour" Rule
The #1 reason for claim rejection is Delayed Intimation.
If you are admitted for an emergency, you MUST inform your insurer (via App/Email/Toll-Free) within 24 Hours. If you delay, they can deny the claim citing "Lack of Opportunity to Verify". Do not wait for discharge to inform them.
The "Room Rent" Trap
Did you upgrade your hospital room? Be careful.
Verdict: If you pick a room above your limit, the insurer applies "Proportionate Deduction". They will cut 50% from your ENTIRE bill (Doctor fee, Surgery, etc.), not just the room rent.
The 24-Hour Rule: Don't Miss This!
The #1 reason for claim rejection is delay in intimation.
- ❌ Emergency: You MUST inform the insurer/TPA within 24 hours of hospitalization.
- ❌ Planned: Inform the insurer at least 48 hours BEFORE admission.
- ✅ Action: Save your TPA/Insurer's Toll-Free number in your phone NOW.
Document Checklist
Whether Cashless or Reimbursement, you need these ready:
- ✅ Health Card: Physical card or e-Card.
- ✅ Govt ID Proof: Aadhaar/PAN of the patient.
- ✅ Doctor's Advice: Prescription advising hospitalization.
- ✅ Policy Number: Keep it handy.
Pre-Admission Check
Filing a claim depends on one major factor: Is the hospital in your insurer's network? If YES, you get Cashless treatment (Insurance pays directly). If NO, you pay first and claim Reimbursement later. Let's look at both processes.
1 Cashless Claim Process (Network Hospital)
This is the most convenient method. You don't pay anything except for non-medical items.
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1
Locate TPA Desk
Upon reaching the hospital, find the "Insurance Desk" or "TPA Desk". Show your Health Card and ID proof.
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2
Pre-Authorization Form
Fill out the Pre-Authorization form. The hospital will add doctor's notes and estimated cost, then fax/email it to your TPA/Insurer.
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3
Initial Approval
The insurer will review and grant "Initial Approval" within 2-4 hours. Admission proceeds. If rejected, you can still treat but must pay cash and claim reimbursement later.
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4
Final Discharge
At discharge, the hospital sends the final bill to the insurer. Once approved (takes 4-6 hours), you pay only for non-payable items (gloves, food for attendant) and leave.
2 Reimbursement Claim Process (Non-Network)
Use this if the hospital is not in your insurer's list. You pay first, insurer pays you later.
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Pay Bill & Collect Originals Pay the full bill. Collect ORIGINAL Discharge Summary, Final Bill (with break-up), Payment Receipts, Lab Reports, and Pharmacy Bills. Do not leave the hospital without these.
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Fill Claim Form Download "Part A" (Customer) and "Part B" (Hospital filled) claim forms from insurer's website. Fill them accurately.
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Submit Documents Submit the signed forms, original bills, KYC (Aadhaar/PAN), and a cancelled cheque (for bank transfer) to the TPA/Insurer within 15 days of discharge.
Cashless vs Reimbursement
| Feature | Cashless | Reimbursement |
|---|---|---|
| Payment | Insurer pays hospital directly | You pay first, claim later |
| Hospital | Network Hospitals Only | Any Registered Hospital |
| Stress Level | Low | High (Paperwork intensive) |
Why Your Claim Amount is Less?
Don't be shocked if you claim ₹1 Lakh and get only ₹85,000. Common reasons:
Gloves, masks, sanitizer, thermometer, admission charges, and attendant food are usually NOT covered.
If your policy limit is ₹5000/day but you take a ₹8000/day room, the insurer deducts proportionately from the ENTIRE bill, not just rent.
Some policies (especially senior citizen) have a 10-20% co-pay clause, meaning you must pay that percentage.
Frequently Asked Questions
How long does reimbursement take?
Once all documents are submitted, the insurer usually settles the claim within 15 to 30 days. If they ask for more queries, it may take longer.
Can I claim from two insurance policies?
Yes. If your bill is ₹5 Lakh and Policy A covers ₹3 Lakh, you can claim the remaining ₹2 Lakh from Policy B. You will need the "Settlement Letter" from the first insurer to claim from the second.
What if my claim is rejected?
Read the rejection letter carefully. If the reason is invalid, you can file a grievance with the insurer. If unresolved, approach the Insurance Ombudsman.