Reimbursement & Cashless Claims Procedure

To avail of the services covered in your health insurance policy, you have to submit a health insurance claim to your insurance company. Health insurance can be claimed in two ways – reimbursement claim and cashless claim.

Cashless Claim Process

In order to avail the cashless claim facility, the insured has to be treated in an empanelled hospital.

The claims process for treatment at a cashless network hospital varies according to the type of treatment – Planned or Unplanned. Unplanned medical treatment at a cashless network hospital usually happens in case of an emergency.

Claims Process for Planned Treatment at the Cashless Network:

The cashless claims process for planned treatment is as follows:

  • You have to submit the cashless claim form to your insurer through letter or email at least five days before the treatment date.
  • The insurance company will inform the hospital after receiving your cashless claim form.
  • You will receive a confirmation letter which will be valid for seven days from the date it was issued.
  • Submit the confirmation letter and health card before admission. Your medical expenses will be paid by the insurance company.
Cashless and Reimbursement Claims in Health Insurance

Claims Process for Emergency Treatment at the Cashless Network:

The cashless claims process for emergency treatment is as follows:

  • You have to notify your insurance company/third-party administrator within 24 hours of hospitalisation. Your Claim Intimation/Reference Number will be generated.
  • The hospital should fill in and submit your cashless claim form to your insurer.
  • An authorisation will be sent to the hospital by the insurance company on receiving your cashless claim form.
  • Your medical expenses will be paid by the insurance company. If your claim is rejected, you will receive a notification about the same on your email address and registered mobile number.
Health Insurance Related Pages

Reimbursement Claim Process

The reimbursement claim for health insurance can be made if the policyholder opts to go to a hospital of his/ her choice, which is a non-empanelled hospital. In this case, the cashless claim facility cannot be used. Therefore, the insured has to pay all his/ her medical bills and other costs involved in hospitalization and treatment and then claim reimbursement.

The reimbursement claims process is as follows:

  • Verify the details mentioned on your medical bill.
  • You have to submit the relevant documents to the insurance company/third-party administrator after you are discharged.
  • The insurance company/third-party administrator will review your documents. The time to review your documents and process the payment can take about 21 days.

You will be notified if your insurer has a query or if your claim is rejected.

Documents Required to Claim Health Insuranc

The following documents are required when making cashless claims or reimbursement claims:

  • Health card
  • Duly filled claim form
  • Medical Certificate/ Form which is signed by the treating doctor.
  • Discharge summary or card (original), availed from the hospital.
  • All bills and receipts (original)
  • Prescription and cash memos from pharmacies/ the hospital.
  • Investigation report
  • If it is an accident case, then the FIR or Medico Legal Certificate (MLC) is required.

GST rate of 18% applicable for all financial services effective July 1, 2017.

Disclaimer: Premiums may vary depending upon factors like age, location and prevailing taxes/GST.

FAQ's

  1. What are the different types of health insurance claims?

    You can claim your health insurance in two ways – cashless claims and reimbursement claims.

  2. What is the difference between cashless claims and reimbursement claims?

    In a cashless claim, your medical expenses are paid by the insurance company at the time of your discharge. In a reimbursement claim, you can pay your medical expenses and later claim for reimbursement.

  3. How long does it take for the reimbursement claim to be processed?

    The insurance company may take up to 21 days to review your documents and process the payment.

  4. When should I inform my insurer if I want to make a cashless claim for planned hospitalisation?

    In case of planned hospitalisation, you should notify your insurer at least five days before the treatment date.

  5. When does a claim get rejected?

    Your claim may be rejected if you make a claim during the waiting period, or for an illness that is not covered by the policy. Another reason for rejection is if you make a false claim.

  6. Is Medico Legal Certificate (MLC) required in case of an accident?

    Yes, a Medico Legal Certificate (MLC) and/or FIR has to be provided in case of an accident

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