Ultimate Guide to Health Insurance Claim

You have paid all your health insurance premiums on time thinking your policy will help you in the hour of need. So when you are battling an unexpected medical contingency, using your health insurance policy is the first thing on your mind. But if your claim is denied, your already stressful situation becomes all the more traumatic.

This health insurance claim guide will give you all the information you need to overcome all the hassles and stress that crop up when you are navigating through the claim process. So, let’s start by getting a better understanding of the different types of health insurance plans that an individual has before getting into the claim process.

  1. Corporate Policy
    A corporate insurance policy is designed to provide health coverage to employees. Corporate policies are generally purchased by employers to provide health insurance benefits to their employees.

  2. Retail Insurance Policy
    Retail insurance policies are individual plans purchased by people to create health cover. A retail insurance policy will ensure that you have additional cover as you continue to switch jobs and provide financial security in case you exhaust the cover in your corporate policy.

    Let us assume that you have two health insurance policies – a corporate policy with a sum insured of Rs. 2 lakh and a retail policy with a sum insured of Rs. 3 lakh. Now if you face a medical emergency and your medical bill at the time of discharge is Rs. 3.5 lakh, you can use your retail policy with a sum insured of Rs. 3 lakh and use the corporate policy to pay the difference amount of Rs. 50,000.

How Lack of Information Regarding the Claim Process Can Hurt You


Now let’s imagine a hypothetical situation to understand what actually happens at the hospital. There is a patient who is having certain symptoms and so, he decides to consult a doctor. The doctor will diagnose the symptoms and prescribe medication or recommend the required treatment. A lot of back and forth happens during this time as people also go from their general practitioner to a specialist for a second opinion and while all of this is happening, the patient gets clarity in terms of his/her medical condition.

And if the problem is persistent and cannot be treated with medication, the doctor will suggest an outpatient procedure or a surgery and hospitalisation. Now this is the instant when the patient is in acute need of funds. This need compels the person to think – can my insurance policy be of any help here?

Now there are 2 buckets of people in this case:

  1. 85% of people feel they are entitled to receiving every health expense from their insurance company.
  2. Only 10 to 15% of people want to know how much their insurance policy will pay. However, the people in this category are very limited in number.

For most people who fall in the first bucket - they only need a Yes/No from their insurance company. And once they get a yes, they assume that any expenses that are incurred up to the amount covered in their policy are payable by the insurance company. So when the policyholder hears a yes – he/she assumes that the insurance company will take care of all the expenses and rarely bothers to ask how much will be provided.

So we can conclude that people lack knowledge and so they never ask – which treatment will be covered? How much will they receive? What is the waiting period? The only thing that people understand is their insurance policy has a cover of 3 lakh so they have 3 lakh to claim.

What they fail to understand is that coverage has a much wider meaning. The term coverage is an umbrella that includes a lot of variables - co-pay, deductions, room rent capping, sub-limits, waiting period, and more. And these are just a few of the many myths that people have when they are filing a claim.


Scenarios in Which the Health Insurance Claim can be Made


You can claim for your medical expenses under your health insurance policy for both planned and unplanned medical contingencies if you fulfill the following conditions:

  • 24 hours hospitalization is needed
    The patient should be hospitalised for at least 24 hours and the need for hospitalisation should be established by a doctor who is qualified to do the diagnosis.

  • Daycare should be covered in the terms of the insurance policy
    Due to advances in medical technology, several surgeries can now be completed in a few minutes. These short-term hospitalisation procedures like cataract, chemotherapy, angiography, and radiotherapy are known as day care procedures. However, it is important to check the list of day care procedures mentioned in your policy documents before claiming under health insurance.

Scenarios in Which You Cannot Claim


Your health insurance can get rejected in the following situations so it is recommended that you check with a SureClaim expert if you are filing a claim.

  • The Tests are Conducted only for Investigation Purpose
    Investigation tests are not covered by insurance companies if the tests results are not leading to any treatment that can cure the patient’s medical condition. So if the doctor is unable to detect a clinical issue and recommend an active line of treatment after the test results have arrived, then the claim will be rejected even if the test was prescribed by a qualified doctor.

  • The hospitalisation is less than 24 hours or if the line of treatment does not fall under any of the daycare procedures listed in your policy
    24 hour hospitalization is required for a claim to be admissible. Also, if the line of treatment is not covered under the policy terms as a daycare procedure and if the patient is not hospitalised for more than 24 hours, then the insured cannot file a claim.

  • If the treatment procedure is not covered in the policy documents
    Any medical treatment or surgery conducted for any procedure that is not covered in the policy terms cannot be claimed.

  • If the claim is filed for a procedure that is listed in the waiting period
    Health insurance policies cover certain pre-existing diseases and diseases that have a high occurrence rate only after a waiting period of three or four years. So if the waiting period is still applicable on your treatment, then you cannot file a claim.

  • If you file a claim for a treatment that is covered but your health insurance policy is not active
    The insurance company will only settle claims when the policy is active. So it is very important to renew your health insurance policy before it expires or within the grace period of 15 days if you want to enjoy continuity benefits from your policy.

Myths Associated with Medical Claims


Due to lack of consumer education, several myths associated with medical claims deter the insured from taking an informed decision. Some of these common myths include:


MYTHS FACTS
The treatments taken at a non-network hospital cannot be claimed. It can be claimed via reimbursement process.
If the claim has been rejected once, the decision cannot be contested. A rejected claim can be contested if you can convince the insurance company that your claim is genuine.
The claim settlement process is always fair. The claim settlement process may not always be fair due to which the insured does not always receive the maximum payout.
The insurance company is liable to pay for all the treatments. The insurance company is only liable to pay for the treatments covered in your insurance policy.
OPD expenses are not covered under a health insurance policy. Certain OPD expenses are covered in the health insurance policy so it is important to refer to the policy documents carefully.
The insured needs to pay the difference of room rent in the medical claim. The insured needs to pay the room rent according to the proportionate deduction applicable in the policy.


There are two ways to claim health insurance


  1. Cashless
  2. Reimbursement

What is a Cashless Claim?


With a cashless claim, the insured is not required to pay for all the treatments and procedures covered under the policy except for the non-medical items. The claim is settled by the insurer who pays to the hospital directly according to the terms and conditions of the policy. Cashless benefits can be availed for both planned and emergency medical treatments.

In order to avail of the benefits available in cashless claims, the insured needs to follow these 4 steps:

  1. Pre-authorisation
    The pre-authorisation process is required to establish trust between the insurance company and the insured. The pre-authorisation process is done to check the eligibility of the claim and to initiate the cashless claim process.

  2. Enhancement During Admission
    When the estimated expense for a medical treatment that is sent at the time of pre-authorisation is lower than the actual amount, then the hospital sends the new expected figure to the insurance company and this is known as an enhancement during admission.

  3. Queries in Cashless Admission
    If any queries are raised during the investigation process of the medical treatment, the hospital needs to resolve those queries.

  4. Cashless Discharge
    Once all the data points are accurately established, the insurance company will settle the payment directly with the hospital.

What is a Reimbursement Claim?


If the hospital where the patient is treated is not a part of the insurance company’s hospital network then the insured has to opt for a reimbursement claim. This requires the insured to pay the hospital bill in cash at the time of discharge and get the payment reimbursed by the insurance company at a later stage. In comparison to cashless medical claims, reimbursement claims are relatively tedious and time-consuming.


The Steps Involved in a Reimbursement Claim


  1. Claim Intimation
    In the case of a reimbursement claim, the insured needs to intimate the insurance company about the admission of the patient to the hospital.

  2. Collecting Documents in the Right Order
    Pre-authorisation is not required in the case of reimbursement claims, but the policyholder is required to collect all the documents and submit them in the right order.

  3. Getting the Documents Reviewed by an Expert Agency like SureClaim
    It is very important to ensure that all the documents are complete and verified by a SureClaim expert before the claim is submitted for reimbursement.

  4. Filling the Claim Form
    The insured can fill the claim form online or by hand or under the guidance of a SureClaim Expert to avoid mistakes and claim rejection.

  5. Claim Submission
    The claim should be submitted with all the required documents listed in the policy terms.

  6. Claim Tracking and Query
    Generally, the insured can keep a track of the claim status online from the insurance company’s website or get in touch with the TPA on their toll-free number. Meanwhile, if a query is raised by the insurance company, the policyholder needs to address it on time.

  7. Query Resolution Advice by an Expert Agency like SureClaim
    The insured should counsel a SureClaim expert for clarity and guidance on resolving the query raised by the insurance company.

  8. Claim Approval and Settlement
    Once all the queries that are raised by the insurance company are resolved in a timely manner and all the documents are verified, the insurance company will approve the claim and settle the payments.

Disputes and Grievances
When do you need to dispute or complaint?


  1. When you have already submitted the claim but your claim id is not generated.
  2. Your claim id has been generated but there is no update in the claim process for over 30 days.
  3. When the insurance company has raised a query regarding a document justifying the medical treatment but you have already submitted the document.
  4. When you have already replied to the query filed by the insurance company but they have not closed the query.
  5. If there are any invalid deductions against the terms and conditions mentioned in your policy.
  6. Documents are not returned when requested for settlement