What is the Time Limit to File a Health Insurance Claim?
Time Frame for Filing a Health Insurance Claim
Health insurance are subject to various timelines that outline how long the insurance company would take to settle the claim. Settling the health insurance claim may take several days or a few weeks, depending on the nature of the claim, whether cashless or reimbursement, the nature of hospitalization, and the procedures followed by the insurance company.
Following is a breakdown of the different timelines typically followed.
1. Cashless Health Insurance Claim Settlement
Cashless claims enable the insured to get medical treatment without any upfront payment, and the insurance company directly settles the bill with the network hospital. Cashless claims tend to take less time compared to reimbursement claims.
●Claim Intimation: As soon as hospitalization is required, the policyholder is expected to inform the insurance company or TPA. Generally, the intimation must be done 48 hours before planned hospitalization, whereas during emergency hospitalization, it must occur within 24 hours.
●Claim Approval: After receiving the claim intimation, the insurer (or TPA) will scrutinize the details, which may take 2 to 4 hours for emergency claims. For planned hospitalizations, the approval may take 1-2 working days.
●Settlement Time: After approval, the insurance company will settle the claim directly with the hospital. Usually, this happens within 24 to 48 hours.
2. Reimbursement Health Insurance Claim Settlement
In a reimbursement claim, the policyholder pays for the incurred medical expenses and then submits the related documents to the insurer for settlement. The period taken to settle the reimbursement claims takes longer than in the case of cashless claims, as it also involves more documentation and processing.
●Claim Intimation: The policyholder has to notify the insurance company about the hospitalization within 24-48 hours. However, it is advisable to inform as soon as possible to avoid delay.
●Submission of Documents: After the treatment, the policyholder must submit all the necessary documents, including hospital bills, discharge summaries, and medical reports. Insurers generally require these documents to be submitted within 30 days of discharge.
●Claim Processing: When the claim documents reach the insurer, normally, it takes 7 to 10 working days for the claim to be processed. However, if the documents aren't complete or the claim is complicated, settlement usually takes longer.
●Settlement Time: If the document is perfect, normally, reimbursement arrives within 15 to 20 working days.
Factors Affecting Claim Settlement Time
Several factors influence the health insurance claim settlement time. Understanding these factors can help policyholders expedite the process:
●Claim Complexity: Simple claims with minimal documentation are processed faster than complicated ones involving high treatment costs, pre-existing conditions, or prolonged hospitalization.
●Documentation: The accuracy of the completed documents submitted for reimbursement claims directly impacts the settlement time. Missing documents or discrepancies often lead to delays.
●Pre-authorization Process: The insurers might take time to check the pre-authorization request, depending on the terms and conditions of the policy. Therefore, this also delays the claim processing timeline.
Claim Settlement in the Event of Disputes or Rejections
At times, there is a rejection or dispute regarding the claims submitted. Such situations cause delays in the claim settlement process. Rejection grounds include:
●Failure to declare pre-existing ailments
●Treatment that is not included in the insurance policy
●Insufficient or inappropriate documentation
If the claim is declined, the policyholder may appeal the decision by lodging a grievance with the insurer or directly approaching the Insurance Ombudsman.
At Star Health, to ensure faster settlement, we process all claims in-house. This enables us to settle 90% of cashless claims in under 2 hours and 92% of reimbursement claims within 7 days, subject to terms and conditions.
What is a Cashless Claim?
A cashless claim in health insurance permits a health insurance policyholder to get medical treatment at a network hospital without paying upfront, as the health insurance company directly settles the medical bill with the hospital. This means the health insurance policyholder don't have to worry about immediate funds needed for treatment or the complexity of reimbursement.
What is a Reimbursement claim?
In health insurance, the reimbursement claim is when you pay for your medical expenses upfront and then submit a claim to your health insurance company to get reimbursement for those expenses. This means you're requesting the health insurance company to pay you back for expenses that you've already paid out-of-pocket.
Also Read:
→ How Much is Health Insurance
→ How Much Tax Can You Save on Health Insurance
→ How No-Claim Bonus Benefits Health Insurance Holders
→ How Often Can You Claim Health Insurance
HELP CENTRE
Confused? We’ve got the answers
Get all your Health Insurance related doubts clarified.
It is based on the type of claim, whether you claim for the health insurance after 1 month. If you require hospitalisation because of an accident, your health insurance will offer coverage of the expenses from day one. But, for most illnesses, there is an initial waiting period of 30 days prior to which you can make a claim.
In case of reimbursement claims, the insurance policyholder must properly inform the health insurance company or their representative 48 hours prior to the planned hospitalisation time. In case of medical emergencies, for the policyholders, the time period limit for reimbursement claims is just 48 hours. The health insurance policy holder must inform their health insurance company before this time period, after the hospitalisation has occurred.
For a cashless health insurance claim, you must require your health insurance card, a pre-authorisation form, a valid photo ID, and medical records, like doctor's prescriptions, discharge summaries, and test reports. You must fill out a claim form given by your insurer.
Claim settlement timelines vary based on the type of claim and how quickly complete documents are submitted. Submitting all documents at once usually speeds up the process.
Claims may take longer if documents are incomplete or if medical review is required. You can always track the status in the App or reach out for updates.
Yes. If cashless is denied, you may submit a reimbursement claim after hospitalization. You can initiate and track this easily through the STAR Health App.
Reimbursement claims are processed after document verification. You can track the status and raise follow‑ups through the STAR Health App.
Cashless must be approved before or during treatment. If not, reimbursement remains the option.
Popular Topics
People Also Search For
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
