How Does Health Insurance Claim Process Work? - Loop

Are you filing a health insurance claim? If so, you should know the correct way to file a claim. Read to know about the health insurance claim process.
How Does Health Insurance Claim Process Work? - Loop

For many policyholders, the most typical question is "after how many days can we claim health insurance?" often known as the waiting period. To get an answer to this question, you must first learn how the health insurance claim process works.

At first glance, the medical insurance claim procedure 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. The insurer's terms and conditions will also annoy you.

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

Let's take a look at how to file a health insurance 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 claiming your health insurance policy benefits from the insurance company.

For example, Mr. A was admitted to the hospital for 48 hours for a medical 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 medical insurance claim, Rs. 1 lakh, which includes all the costs he can claim, will be compensated by the insurer to Mr. A.

Let's look at the various types of claims and how to claim health insurance.

The Different Types of Claims:

1. Cashless Claims:

A cashless claim is a mode of claim settlement. Simply put, a cashless claim process is a part of the health insurance 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 are the medical insurance claims processing steps:

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 health insurance 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 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.

Here's what you have to do as part of the health insurance reimbursement process when you file a reimbursement claim:

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 medical receipts
  • Hospital discharge card
  • Doctor’s prescription
  • If the medical insurance claim amount is above Rs. 1 lakh, then a CKYC Form
  • Reports like X-rays, etc.
  • Medical certificate by a doctor
  • Obtain a copy of the FIR / MLC before being discharged from the hospital in the event 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 required to submit to the insurer.

Tip: Before you send the claim 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 them in the future.  

Step 4 - The third-party administrators (TPA) will verify 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.    

It's not that tough once you understand the processes involved in the reimbursement claim process.

We hope you now know how to claim medical insurance.

Loop Is Here To Help You In Health Insurance Claim Process:

Loop Health ensures that apart from providing you with one of the best-in-class policies, at a time of need, the medical insurance claim procedure 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 health insurance claim 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.  

Are you ready to enjoy all that Loop offers?

Interested in learning more about Group Health Insurance? Click here

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