Guide To Dealing With Health Insurance Claims

A detailed guide to know everything about health insurance claims
Team Loop Health
June 11, 2021

At first glance, the process to file a claim is not as straightforward as it may seem. Plus, the last thing you want to do is spend hours filling forms and getting bogged down with paperwork.

Keeping this in mind, insurers want the process to be as smooth, easy, transparent, and fast as possible. The primary priority is to support you through the process and ensure you understand what’s happening every step of the way, so you get what you need as soon as possible.

Let’s quickly walk you through filing a claim.

What Is A Health Insurance Claim?

Once you purchase health insurance, you get cover in the form of a sum insured. In case of any treatment costs, hospitalizations, emergencies, etc. this sum insured provides financial aid. After you make a claim with your insurer, they will register and study your claim. Once approved, the medical treatment costs will be reimbursed.  

In other words, claiming health insurance is the process of claiming your health insurance policy benefits from the insurance company.

For example, Mr. A was admitted to the hospital for 48 hours for an emergency. The hospital bill, including doctor’s fees and other medical costs, is Rs. 1.5 lakhs. Mr. A’s comprehensive coverage policy has a sum insured of Rs. 6 lakhs. So, when he files a claim, Rs. 1 lakh, which includes all the costs he can claim, will be compensated by the insurer to Mr. A.

The Different Types of Claims

1. Cashless Claims

A cashless claim is a mode of claim settlement. Simply put, a cashless claim is a part of the claim settlement process where the insurer settles the bill directly with the network hospital and you, the policyholder, only pay a nominal amount.

There are two types of cashless claims:

  • Planned
  • Emergencies

I. Planned hospitalization

Planned hospitalization is when you’re aware of the hospitalization beforehand and you’ve set a date for your surgery, treatment or hospitalization. In such cases, here’s what you have to do:

Step 1 - Get a hold of the pre-authorization form, which is available at the network hospital. This form includes an estimate of the treatment.

Step 2 - Hand this form over to the insurer, at least a week in advance.

Step 3 - After the insurer receives your form, they will notify the hospital and give you a confirmation letter that’s valid for seven days.

Step 4 - On the day you’re getting admitted, submit your health card and confirmation letter to the hospital.

Now, it’s time for you to prepare for treatment and take care of your health, while the insurer settles your bill.

II. Emergency hospitalization

Emergency hospitalization is when it’s unforeseen, unplanned, or an emergency. At such a time, you have to:  

Step 1 - Inform the insurer within 24 hours of hospitalization so they can generate the claim intimation. At such a time, you need a few documents like:

  • A copy of the policy
  • Insurance card
  • Photo ID proof and address proof
  • If the claim amount is over 1 lakh, then you need a duly filled CKYC Form

Step 2 - Get the cashless claim form filled by the hospital and submitted to the insurer.

Step 3 - Once the cashless form is submitted, the hospital will receive an authorization letter from the insurer. If approved, your costs will be paid by the insurer. In case of rejection, you will get a notification on your registered mobile number and email ID.

Tip: It’s extremely important to know what your policy covers and doesn’t cover, so you can avoid any last-minute hiccups, or surprises.

2. Reimbursement Claims

As the name suggests, a reimbursement claim is a type of insurance settlement where you bear the costs of treatment or hospitalization on your own and the insurer reimburses you at a later stage.

There are two types of reimbursement claims:

  • At a network hospital - Has a tie-up with the insurer and provides cashless treatment
  • At a non-network hospital - Not part of the network and has no tie-up with the insurer

The primary difference between the two is that cashless claims aren’t applicable at non-network hospitals.

When you file a reimbursement claim, here’s what you have to do:

Step 1 - At the time of paying the bill, ensure everything is in order and verify all the details.

Step 2 - To file a reimbursement claim, you need a handful of documents such as:

  • Signed and filled claim form
  • Copy of the policy
  • Insurance card
  • Original bills and receipts
  • Hospital discharge card
  • Doctor’s prescription
  • If the claim amount is above Rs. 1 lakh, then a CKYC Form
  • Reports like X-rays, etc.
  • Medical certificate by a doctor
  • Copy of FIR / MLC, in case of an accident
  • Your contact info and bank account details

Some documents may take a while to procure, ensure you constantly follow up to procure them.

Step 3 - Once you get a hold of all the documents, submit them to the insurer

Tip: Before you send the documents to the insurer, ensure you thoroughly review and double-check them to ensure nothing is missing. It’s also important to make copies for safekeeping or in case you need it in the future.  

Step 4 - The insurer will review the documents. This may take about 2 to 3 weeks. If the insurer approves, they will send the money to your account. If the insurer rejects the claim, you will get a notification on your registered mobile number or email ID.    

If you think of it, once you know the steps involved in the process, it’s not that difficult.

And We’re Here To Help

Loop Health ensures that apart from providing you with one of the best-in-class policies, at a time of need, the claims process is as stress-free as possible.

Plus, the Loop Health app makes life easier.

The app is a one-stop shop for all your informational needs. With just a few taps, you know everything you need about your health insurance plan. Whether you want to get on a video call with a specialized doctor, check the inclusions and exclusions of your policy, or drop by one of the network hospitals for a check-up, all this information and more is present at the tip of your fingers.  

Keeping in mind your busy lives, Loop’s process is straightforward, and breaks down and simplifies everything you need to know about insurance.  

Don’t forget if you need any assistance, our round-the-clock service will answer all your queries.  

If you’re ready to enjoy all that Loop has to offer, click here.

Interested in learning more about Claims in Group Health Insurance? Click here

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