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Health Insurance Claims Covering Life, Protecting Health.

If the illness, injury, or accident is covered by your health insurance policy, you are eligible to file a  claim. For planned hospitalization, it is essential to inform the insurance company about the claim 72  hours before admission. It is important to note that the treatment must be taken within 15 days of  receiving authorization. In the case of emergency hospitalization, you must inform the insurance  company within 48 hours of admission or before discharge, whichever is earlier. 

Types of Health Insurance Claims

Understanding the different types of health insurance claims is crucial for policyholders and beneficiaries. Health Insurance claim process is classified mainly into below categories i.e. Cashless claim, Reimbursement claim . Let's discuss the process in detail. Let's take a closer look at the reasons behind these rejections;

  • CASHLESS CLAIM

  • Health Claims

    Cashless Claim

    The cashless claim facility keep you worry free during a medical emergency as you can avail any of treatment at the network hospitals. Which is empanelled with your  insurance company. The bills are settled directly between the hospital and the insurance company.  It reduces the stress of making direct cash payments to the hospital. Cashless claim process for health insurance will depend on the type of hospitalisation you are facing. Here’s a more detailed breakdown of the steps involved;

    Planned Hospitalisation

    In this case, the insured is aware of the hospitalization few days in advance. In such a scenario:

    • Please contact your service provider or TPA help-line mentioned in the Health Identity Card
    • Fax /submit the required documents. E.g. Doctor's certificate, medical bills etc.
    • Obtain approval from the Service Provider or TPA

    Unplanned/ Emergency Hospitalisation

    In this case, the insured meets with a sudden accident or suffers from illness that requires immediate admission to the hospital. In case of such emergency hospitalisation:

    • The patient is to be rushed to the hospital
    • Patient avails treatment
    • Family/Friends/Employer to contact Service Provider or TPA help-line as mentioned in the Health Identity Card

    Cashless Claim Process

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    Intimate Your Claim

    In a emergency hospitalisation, the insured needs to intimates insurer within 24 hours . While you choose to go for a cashless claim, first and foremost, remember your treatment should be at the network hospitals

    number--small--2

    Document Submission

    Submit all the required documents at the TPA or upload online them on the app if available . 1- KYC 2. Claim Form 3. Doctor Prescription. Additional documents has to be provided by the insured during the process.

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    Health Insurer Approval

    The insurer will verify all the documents, in case of any additional requirement, claims team shall raise the query which needs to be fulfilled by the insured within the timeline. 

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    Claim Settlement

    Once the formalities are completed the insurance company will settle the bills with the hospital according to the terms and conditions.

  • REIMBURSEMENT CLAIM

  • Health Claims

    Reimbursement Claim

    This option is available when you receive treatment at a non-network hospital or opt for treatment that is not covered under the cashless facility. You pay the hospitalisation cost  and then get the bill amount reimbursed by the insurance company. You can file for reimbursement of expenses by submitting the necessary documents such as bills, medical reports, and other supporting documents. 
    Remember: While leaving the hospital make sure to ask for Original Copies of all the treatment related documents and the bills and receipts. These documents are crucial when making a  reimbursement claim. 

    Reimbursement Claim Process

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    Intimate Your Claim

    Register your claim within the 15 days by filling the claim form and prepare all the original documents as per the list mentioned in the claim form (Ensure to have a set of copies of all the documents for self-purpose)

    number--small--2

    Document Submission

    Scan and upload the documents online on the app if available or submit all the original document at the nearest branch of the insurance company. Insured can also courier the documents at the insurance company.

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    Health Insurer Approval

    The insurer will verify all the documents, in case of any additional requirement, claims team shall raise the query which needs to be fulfilled by the insured within the timeline. Once all the requirement is fulfilled claim is processed

    number--small--4

    Claim Settlement

    Once the requirements are completed the insurance company, they will settle the bills according to the terms and conditions. Any expenses which are not covered in the policy will not be reimbursed.

  • DOCUMENTATION

  • Documents Required

    Smooth processing of life insurance claims necessitates proper documentation. Typically, required documents are as follow;

    Cashless Claim

    Documents Required for Cashless Health Insurance Claim:

    • Submit the duly filled pre-authorization claim form
    • Policy health card
    • Identity proof of the insured
    • Doctor’s prescription for hospitalisation
    • Treatment-related documents, previous diagnostics, etc

    ReimbursementClaim

    Documents Required for Health Insurance Claim Reimbursement:

    • Duly filled and signed claim form and copy of Insurance policy or health card
    • Original Discharge card issued by the hospital
    • Original final hospital bill with item wise break-up
    • Original paid receipt against the final hospital bill
    • Attested copy of indoor case papers
    • Doctor's Consultation Papers
    • Prescriptions and medical store bills
    • Doctor prescribed consumables and disposables
    • All Investigation and Test reports
    • NEFT details/ Cancelled Cheque of insured bank for reimbursement
    • Any other document asked by the TPA/Insurance company
    • For all claims amounting Rs.1 lakh or above please provide copy of any one of these KYC documents (Aadhaar Card, Passport, Driving Licence Voter ID, etc). Please ensure that the address on KYC documents is matching with the Policy address
    • In case of an accident, Xerox of FIR or medico-legal certificate (MLC)
Health Claims

Cashless Claim

The cashless claim facility keep you worry free during a medical emergency as you can avail any of treatment at the network hospitals. Which is empanelled with your  insurance company. The bills are settled directly between the hospital and the insurance company.  It reduces the stress of making direct cash payments to the hospital. Cashless claim process for health insurance will depend on the type of hospitalisation you are facing. Here’s a more detailed breakdown of the steps involved;

Planned Hospitalisation

In this case, the insured is aware of the hospitalization few days in advance. In such a scenario:

  • Please contact your service provider or TPA help-line mentioned in the Health Identity Card
  • Fax /submit the required documents. E.g. Doctor's certificate, medical bills etc.
  • Obtain approval from the Service Provider or TPA

Unplanned/ Emergency Hospitalisation

In this case, the insured meets with a sudden accident or suffers from illness that requires immediate admission to the hospital. In case of such emergency hospitalisation:

  • The patient is to be rushed to the hospital
  • Patient avails treatment
  • Family/Friends/Employer to contact Service Provider or TPA help-line as mentioned in the Health Identity Card

Cashless Claim Process

number--small--1

Intimate Your Claim

In a emergency hospitalisation, the insured needs to intimates insurer within 24 hours . While you choose to go for a cashless claim, first and foremost, remember your treatment should be at the network hospitals

number--small--2

Document Submission

Submit all the required documents at the TPA or upload online them on the app if available . 1- KYC 2. Claim Form 3. Doctor Prescription. Additional documents has to be provided by the insured during the process.

number--small--3

Health Insurer Approval

The insurer will verify all the documents, in case of any additional requirement, claims team shall raise the query which needs to be fulfilled by the insured within the timeline. 

number--small--4

Claim Settlement

Once the formalities are completed the insurance company will settle the bills with the hospital according to the terms and conditions.

Health Claims

Reimbursement Claim

This option is available when you receive treatment at a non-network hospital or opt for treatment that is not covered under the cashless facility. You pay the hospitalisation cost  and then get the bill amount reimbursed by the insurance company. You can file for reimbursement of expenses by submitting the necessary documents such as bills, medical reports, and other supporting documents. 
Remember: While leaving the hospital make sure to ask for Original Copies of all the treatment related documents and the bills and receipts. These documents are crucial when making a  reimbursement claim. 

Reimbursement Claim Process

number--small--1

Intimate Your Claim

Register your claim within the 15 days by filling the claim form and prepare all the original documents as per the list mentioned in the claim form (Ensure to have a set of copies of all the documents for self-purpose)

number--small--2

Document Submission

Scan and upload the documents online on the app if available or submit all the original document at the nearest branch of the insurance company. Insured can also courier the documents at the insurance company.

number--small--3

Health Insurer Approval

The insurer will verify all the documents, in case of any additional requirement, claims team shall raise the query which needs to be fulfilled by the insured within the timeline. Once all the requirement is fulfilled claim is processed

number--small--4

Claim Settlement

Once the requirements are completed the insurance company, they will settle the bills according to the terms and conditions. Any expenses which are not covered in the policy will not be reimbursed.

Documents Required

Smooth processing of life insurance claims necessitates proper documentation. Typically, required documents are as follow;

Cashless Claim

Documents Required for Cashless Health Insurance Claim:

  • Submit the duly filled pre-authorization claim form
  • Policy health card
  • Identity proof of the insured
  • Doctor’s prescription for hospitalisation
  • Treatment-related documents, previous diagnostics, etc

ReimbursementClaim

Documents Required for Health Insurance Claim Reimbursement:

  • Duly filled and signed claim form and copy of Insurance policy or health card
  • Original Discharge card issued by the hospital
  • Original final hospital bill with item wise break-up
  • Original paid receipt against the final hospital bill
  • Attested copy of indoor case papers
  • Doctor's Consultation Papers
  • Prescriptions and medical store bills
  • Doctor prescribed consumables and disposables
  • All Investigation and Test reports
  • NEFT details/ Cancelled Cheque of insured bank for reimbursement
  • Any other document asked by the TPA/Insurance company
  • For all claims amounting Rs.1 lakh or above please provide copy of any one of these KYC documents (Aadhaar Card, Passport, Driving Licence Voter ID, etc). Please ensure that the address on KYC documents is matching with the Policy address
  • In case of an accident, Xerox of FIR or medico-legal certificate (MLC)

Reason for Claim Rejection

Having health insurance is crucial for ensuring financial protection in case of medical emergencies. However, there are certain instances where the health insurance company rejects the claim as a last resort. As a policyholder, you would never like to face this situation of a health insurance claim getting rejected. The event of a self or family member getting hospitalised is stressful, and the claim getting rejected only adds further to the stress. According to BimaSure out of the total claims rejected, 75% rejection are due to limited understanding and non disclosure of pre existing diseases.
Let's take a closer look at the reasons behind these rejections:

Undisclosed pre existing medical

Majority of claims are rejected due to insured member not being transparent during policy purchase

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Waiting Periods

Claims are rejected due to incomplete waiting period

Wrongly filed claim

Rejection also occur due to inaccurately filed claims, emphasizing the necessity for clearer customer guidance during claims

Unsubmitted query reverts

Rejections also arise due to unsubmitted query revert within the timelines

Claims outside coverage

claim rejections occur due to ailments not covered or non-payable claims

Unjustified hospitalisation

This is also one of the reasons for claim rejection, therefore it is very important to understand the criteria for justified hospitalisation as per policy terms.

Tips To Avoid Claim Rejection

Health Insurance offers a vital protection to the policyholders, yet navigating the claim process and preventing claim rejection requires understanding and precautions to minimise the stress and ensure coverage, Here are some preventive measures to avoid claim rejection;

Verify Coverage

Before seeking any medical treatment, thoroughly review your policy to understand what expenses are covered and any pre-authorization requirements

Review Exclusions and Limitations

Familiarise yourself with the exclusions and limitations stipulated in your policy. Knowing what is not covered can help you avoid using services or treatments that are not eligible for reimbursement.

Provide Accurate Information

Double-check that all personal details, including name, address, and policy number, are correctly entered on the claim form. Ensure all medical information and treatment descriptions are accurate as well.

Submit claims Promptly

File your claim as soon as possible to avoid missing any deadlines imposed by your insurer. Timely submission increases the chances of receiving your reimbursement.

Keep Documentation

Maintain records of all medical bills, prescriptions, and invoices, as well as any supporting documents related to your claim. This will expedite the process and protect against discrepancies.

Follow Procedures

Understand the specific claim filing requirements of your insurance company. This may include filling out specific forms, attaching necessary documents, or adhering to certain billing practices.

FAQ's

As the need for insurance increases, doubts and queries also increase. Navigating insurance complexities can be overwhelming. To help you with this, We have tried to address common doubts for a seamless journey with Bimasure;

A health insurance claim is a formal request by a policyholder to the insurance company for funds to cover medical expenses, treatments, or conditions listed in the health insurance policy 

Available types include Individual Health Insurance, Family Floater Health Insurance, Senior Citizen Health Insurance, Group Health Insurance, Critical Illness Insurance, and Preventive Healthcare Plans.

Cashless claims allow medical treatment at a network hospital without direct payments, with the hospital bills settled by the insurance provider. Reimbursement claims involve paying for medical treatment out of pocket and later filing a claim for reimbursement 

Required documents include identity proof, policy document, medical reports of the illness, hospitalization papers, medicine bills, ambulance bills, discharge papers, and any other costs related to the treatment 

For planned treatment, inform the insurance company in advance and submit all medical reports of the illness. The company will assess the reports and disburse funds accordingly 

For unexpected hospitalization, submit the diagnosis report of the illness along with admission papers from the hospital. The company will offer an instant lump sum payout for all healthcare needs 

In reimbursement claims, the insurance company reviews the medical bills and repays the policyholder for the amount spent up to the policy coverage limit 

After verifying the claim documents, the insurance company processes and credits the reimbursement to the policyholder’s bank account 

Claims may be denied due to incomplete documentation, discrepancies in information, or for treatments not covered under the policy 

To speed up claim processing, notify the insurer immediately after hospitalization, submit all required documents promptly, and follow up regularly with the insurance company 

If a claim is rejected, policyholders can submit a written appeal, providing additional information or clarifications needed, and use the insurance company’s grievance redressed mechanism.

The first step is to notify the insurance company as soon as possible after hospitalization, either through their customer care helpline or by sending an email 

The second step is to submit the required documents to the insurance company, including the policy document, claim form, medical certificate, hospitalization bills, and diagnostic reports 

The fifth step is to submit the claim for reimbursement by submitting the original bills and receipts to the insurance company along with a reimbursement claim form 

Why Choose Bimasure for Health Insurance

At Bimasure, Right from comparing policies to buying and making a claim, Bimasure offers you complete insurance solutions right at your fingertips. Here's why thousands choose us for their health coverage needs.

Expert Guidance

Our team of experienced advisors is ready to guide you through the complexities of health insurance, helping you make informed decisions that safeguard your health and financial future.

Tailored to Your Needs

We recognize that every individual and family has unique health requirements. Our Wide choice of Insurance products allow you to tailor coverage that aligns perfectly with your specific needs.

Convenience and Hassle-free

We deliver your insurance needs with smart tech, We believe in issuing instant policies and provide an hassle-free experience of buying insurance in the simplest possible way for all our valued policyholders

Trusted and Transparent

At Bimasure, transparency is our hallmark. We believe in communicating with customers transparently about company’s offerings and capabilities.

Claims Assistance

Complete claim assistance with regards to queries, documentation and claim settlement at any time during the policy tenure.

Invest in Your Health Today for a Secure Tomorrow. Choose Bimasure – Your Partner in Wellness!

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