How Can I Claim Medical Insurance?
Medical Insurance Claim: A Comprehensive Guide
Knowing the right processes for health insurance claims can help you reap the benefits of your insurance when you need it the most. However, for that, you need to have a clear idea of the steps, documents required, and common reasons for rejection.
This guide covers just that, enabling you to file quick claims, regardless of whether you are opting for cashless treatment at a network hospital or claiming reimbursement.
Methods to Claim Medical Insurance
There are two main ways in which medical insurance claims can be settled: Cashless or Reimbursement:
Cashless Claims :
1. Network Hospitals: When hospitalization is needed, opt for treatment in hospitals that belong to your insurer’s network.
2. Pre-Authorization: Notify the hospital’s insurance desk of your policy and complete a pre-authorization form
3. Approval: The hospital submits the form to your insurer for approval. Once the claim is approved, the insurer pays the bills directly to the hospital.
Reimbursement Claims:
1. Non-Network Hospitals: If you go to a non-network hospital, you must cover the bills upfront.
2. Gather Documents: Collect all the required documents, like hospital bills, discharge summaries, and prescriptions.
3. Submission: Submit these documents along with a duly filled claim form to your insurer.
4. Processing: The insurer then verifies the documents and transfers the admissible amount to your bank account.
Comparison of Cashless and Reimbursement Claims
Aspect Cashless Claims Reimbursement Claims:
Hospital Network Requires treatment in-network hospitals. Applicable for both network and non-network hospitals.
Payment Process The insurer settles bills directly with the hospital. The policyholder pays upfront and gets reimbursed later.
Pre-Authorization Mandatory before treatment, except in emergencies. Not required, but prior intimation is advisable.
Documentation Minimal, as the hospital coordinates with the insurer. Extensive, including all original bills and reports.
Processing Time Faster, as approvals are obtained before or during hospitalization. Longer, as the insurer reviews documents post-treatment.
What Documents are Required for a Health Insurance Claim?
A well-managed documentation is essential for a smooth claim procedure. Commonly required documents include the following:
● Claim Form: The form should be completed and signed.
● Hospital Bills: Copy of final, itemized bills and payment receipts.
● Discharge Summary: A detailed report of when you are discharged from the hospital.
● Prescriptions: Doctor’s prescriptions for medicines and tests.
● Laboratory Reports: Results of lab tests, such as blood work, X-rays, MRI scans, etc.
● Policy Documents: Health insurance policy copy, ID proof.
Having all the paperwork in order can speed up the claims process.
How to Check the Status of My Health Insurance Claim?
You can check your health insurance claim status via the following methods:
● Through Online Portal: Visit your insurance provider’s official website and go to the claim status page.
● Mobile App: You can check the status of your claim using the insurer’s app.
● Customer Support: Call the insurer’s customer service helpline.
● Email Updates: Certain insurers offer email alerts throughout the claim process.
Star Health Insurance, for instance, provides several channels: its website, app, and a 24/7 customer support helpline for policyholders to easily track the status of their claims.
Rejection of Claims
In case of partial or full rejection of your claim, just review the rejection letter to know the reasons behind it. If you think that the rejection was unjustified, you can make an appeal for the decision. You may have to submit extra documents or give clarifications to support your case. Understand limits and Waiting Periods of the policy, as the awareness of these can help one avoid unexpected surprises during the claims process.
Common Reasons for Health Insurance Claim Rejection
Check out some of the common reasons which can lead to health insurance claim rejections:
● Documentation Issues: Documents are either missing or incorrect.
● Policy Exclusions: Treatments not covered as per the policy.
● Claims During the Waiting Period: Claiming health insurance for pre-existing diseases, maternity coverage, or specific ailments within the waiting period will lead to rejections.
● Non-Disclosure: Not declaring any pre-existing conditions when purchasing the policy.
● Delayed Submission: Failing to notify the insurer or filing claims within the required time period.
Understanding these factors and systematically following the claim process can increase the probability of a successful claim. Also, choosing an insurer with a high claim settlement ratio is a must.
Why do you need a Medical Insurance?
Medical insurance is important as it offers financial security against high medical costs, enhances access to health services, and offers preventive care. A few plans help with health of family, home treatment, and treatment for lifestyle diseases.
Also Read:
→ How to Get Braces Covered by Medical Insurance
→ How to Get Dental Implants Covered by Medical Insurance
→ How to Get Pradhan Mantri Medical Insurance
→ Is Medical Insurance Mandatory for Employees in India
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The policyholder can raise a claim when he/she need money for treatment of a minor or major illness which is listed under the health plan, injury, accident, or any other medical condition.
In general, there are two types of health insurance claims. They are cashless and reimbursement claims. Learning about the claim types in healthcare makes sure you have a seamless claim settlement experience.
You can file a health insurance claim by informing your insurer as soon as you are admitted, submitting the required documents like medical bills and reports, and following their claim process. For cashless claims, contact the hospital insurance desk. For reimbursement, pay the bills first and then submit all documents to the insurer.
The two ways of making health insurance claims are cashless and reimbursement
You can claim health insurance benefits in two ways: cashless or reimbursement. Cashless means that you do not have to pay anything at the time of admission or discharge from the hospital.
The list of documents that you may require to file for reimbursement health insurance claims includes an original claim form duly completed along with your signature, valid identity proof, a doctor's prescription suggesting treatment in the hospital, Doctor's prescription advising diagnostic tests, medicines, and consultation, final hospital bill and payment receipts, hospital discharge summary, indoor case papers, ambulance receipt, original pharmacy bills, First Information Report(FIR whenever required), policy copy or health card issued by the insurer.
You can file a claim in easy steps by visiting the link - https://customer.starhealth.in/customerportal/claimIntimationWithoutLogin. You can also file a claim by contacting us at 044 6900 6900 / 044 4674 5800 / 1800 425 2255 / 1800 102 4477, e-mailing us at support@starhealth.in or using WhatsApp chat service @ +91 95976 52225.
You can check your claim online by clicking on the link. You can also check your claim status via: Call: 1800 425 2255 / 1800 102 4477, E-Mail: support@starhealth.in WhatsApp: +91-9597652225.
You can file a reimbursement claim by submitting the following documents:
1. Claim form
2. Test reports (from Govt. Approved Laboratories)
3. Bills for the tests undergone
4. Discharge summary from the hospital
5. Bills from the hospital
6. Bills for purchased medicine
7. All payment receipts
8. Copy of PAN card, cancelled cheque or NEFT details
No matter how many times you make a claim, it is not limited. You can make claims up to the limits of your sum insured.
The insured gives prior intimation about the treatment and the insured pays the expenses himself to the hospital and then claims for a reimbursement of those expenses within 15 days from the date of discharge.
- Documents to be submitted for Reimbursement claims.
- Duly completed claim form.
- Pre-admission investigations and treatment papers.
- Discharge summary from the hospital.
- Cash receipts from the hospitals and chemists.
- Cash receipts and reports for tests done.
- Receipts from doctors, surgeons and anesthetists.
- Certificate from the attending doctor regarding the diagnosis.
- Copy of PAN card cancelled cheque or NEFT Details.
Yes, you can claim medical bills without hospitalization through health insurance if your medical health insurance plans cover OPD or domiciliary hospitalization.
You can claim any number of times in your health insurance policy until your sum insured is not exhausted.
If your cashless claim is denied, the first thing you should do is ask the hospital’s TPA or insurance desk for the reason. Most of the time, it happens because of missing documents, eligibility issues, or incomplete pre-authorisation. After that, contact your insurer right away to find out what is missing and send any extra documents they need. If your claim is still not approved in time, you can pay the bill yourself and later file a reimbursement claim with all your bills, discharge summary, and medical reports. This way, you can still get your benefit even if the cashless claim does not go through.
Post-hospitalization expenses are the costs you pay after you leave the hospital, but still for the same treatment. These can include follow-up visits to your doctor, tests, medicines, and physiotherapy that your doctor asks you to do. Most health insurance plans will cover these expenses if you claim them within a certain number of days, usually between 30 and 90 days, depending on your policy.
If you need to write a letter to your health insurance company, it’s best to follow a simple business letter format. First, write your full name, address, and contact number at the top, then add the date. After that, write the insurance company’s name, the right department (like Claims or Customer Service), and their address. If you know the name of a specific person, include it to make sure your letter reaches them quickly. It’s also a good idea to mention your policy number or claim number in the subject line so your letter goes to the right team. Start your letter with a formal greeting and clearly say why you are writing in the first paragraph. Always keep your letter polite, short, and to the point.
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This FAQ page contains information for general purpose only and has no medical or legal advice. For any personalized advice, do refer company's policy documents or consult a licensed health insurance agent. T & C apply. For further detailed information or inquiries, feel free to reach out via email at marketing.d2c@starhealth.in
