Claim Settlement: Simplified Guide to Health Insurance Claim Process

Ruby McKenzie
6 Min Read

There is no denying that health insurance is an essential investment to maintain financial stability in the face of medical emergencies. In exchange for regular premium payments, you can ensure that you and your loved ones can access timely medical treatment whenever required without worrying about the bills.

But, to be able to avail the above benefits of a health policy, you must first file a claim. Lack of knowledge about the claim settlement process or missing documentary requirements can compromise your insurance coverage. But, worry not, the following sections will provide all the necessary information to help you file an insurance claim successfully. Let’s get started!

Cashless Claim vs Reimbursement Claim Process

Before starting with the steps involved in claim settlement, it’s important to familiarise yourself with the two types of claims that you can file with insurers. These are:

Cashless Claim

As part of a cashless policy, you can avail yourself of the medical treatment at a network hospital without paying the bills upfront. The health insurer settles the medical bill directly with the hospital. This means you don’t have to worry about arranging funds or waiting for reimbursement, thus reducing your financial burden.

Reimbursement Claim

As the name suggests, reimbursement-based policies require you to first pay the medical bills to seek treatment. You can then file a claim with the necessary documents, and the insurer will reimburse you the amount you had previously paid, subject to the upper limit of the sum assured amount.

Health Insurance Claim Process of Leading Insurance Companies

Different companies may prescribe different steps to file claims. However, the best insurance companies in India like Niva Bupa follow the below-mentioned health insurance claim process:

Cashless Claim Process

Cashless claims excel in providing immediate access to treatment without the need for upfront payments. The cashless claim settlement process is hassle-free and provides peace of mind. It involves steps such as:

Planned Hospitalisation

  • In this case, you must first choose a network hospital that fits your convenience. For instance, Niva Bupa allows you to access cashless treatment at 10,000+ hospitals, as mentioned on their website.
  • Once you are sure about the hospital you want to get treated at, you must visit their TPA (Third Party Administrator) desk two days prior and complete a pre-authorisation form.  For this task, you will require details like health card number, patient’s photo, OPD prescription, investigation reports, and KYC documents.
  • Top insurers like Niva Bupa will then verify your claim and inform you regarding the final decision within 30 minutes. The claim amount is processed within 2 hours of receiving the documents from the hospital’s TPA desk.

Emergency Hospitalisation

If you are faced with an emergency, you must get admitted to your nearest hospital. If the hospital is empanelled with the insurer, you can follow the same process as mentioned above. However, if the hospital is not empanelled, you can follow the reimbursement process explained in the next section.

Reimbursement Claim Process

Reimbursement claims can offer you the benefit of flexibility and choice. You can seek treatment at any hospital you prefer, even if it’s not within the insurer’s network, and later claim the expenses incurred. The steps involved are mentioned below:

Arrange Documents

You must arrange and scan the following documents in addition to the policy number and date of birth of the primary policyholder:

  • Discharge summary
  • Bills & receipts
  • Investigation reports
  • Cancelled cheque with the name printed
  • KYC documents like recent photo and identity proof of the patient

Enter Claim Request

Once you have all the documents, you must log in to the insurer’s website and fill out the claim form. You must enter details like policy number, date of birth, cause of hospitalisation, location, date of admission and discharge, claim amount, etc.

Upload Documents

After correctly filling out the claim form, you must upload the documents in a format suggested by the insurer. You should verify all documents before submitting them as your claim will be assessed based on such details.

Receive Intimation

Based on the verification of your details, the insurer will decide to accept the claim request. Top insurers like Niva Bupa follow a quick timeline and process the claim within 7 days. You will be informed about the claim status via email and SMS.

Summing Up

With this information, you are now ready to file claims in the right manner and improve your chances of getting them accepted. In addition to the above steps, you must also disclose complete information about your treatments and maintain transparency with the insurer.

The best health insurance companies in India like Niva Bupa are known for their smooth and efficient claim settlement process. Niva Bupa settles the claims directly within 30 minutes without third-party involvement and has a high claim settlement ratio of more than 95%. Learn more about their policies and take the benefit of their hassle-free procedures today!

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