While most insurers have made the process of buying health insurance seamless and hassle-free, many policyholders get overwhelmed with the process of filing a claim and getting it approved. However, if you understand the process of filing a claim, the process can become much simpler, and the chances of rejection can minimize. Today, we will be taking you through the process of filing a mediclaim.

Filing a claim for health insurance

There are two broad ways of filing a claim for health insurance:

  1. Cashless
    1. Planned
    2. Emergency
  2. Reimbursement

How to file a Cashless Mediclaim?

As the name suggests, a cashless mediclaim is when the insurance company pays all the covered expenses directly to the hospital on your behalf. The insurance company offers this facility on a network of approved hospitals. Cashless mediclaim are of two types: planned and emergency claims.

Planned Cashless Mediclaim

Sometimes, you plan surgeries or treatments well in advance and know that you will have to be hospitalized. This is a planned treatment. If you have opted for a cashless health insurance policy and have planned a medical procedure, then you can follow these steps:

  • Most insurers have a requirement of receiving an application from the policyholder a few days before the treatment. Check the timelines with your insurer and ensure that you submit the application within time.
  • The insurer verifies your application and sends you a cashless confirmation letter while informing the hospital too. This letter has an expiry date, and you need to ensure that you get the treatment done within the deadline.
  • Once you reach the hospital for the treatment, submit the cashless confirmation letter and your health card.

That’s it! The insurer and the hospital do the rest.

Emergency Cashless Mediclaim

Medical treatments aren’t always planned. Accidents or sudden emergencies can result in hospitalization. If you have a cashless health insurance policy and have an emergency treatment at the hospital, then you need to follow these steps to file an emergency cashless mediclaim:

  • Usually, insurers insist on receiving information about an emergency treatment within 24 hours of being hospitalized
  • The hospital also asks the policyholder to fill a cashless request form 
  • The documents needed are your insurance card, proof of identity, proof of address, KYC form, and a copy of the policy.
  • Once you submit the claim form, the insurance company issues a letter of authorization to the hospital.

Whether the treatment is planned or arising out of an emergency, if the insurer rejects your claim, you will be informed about the same via a letter or email.

How to file a Reimbursement Claim?

Some insurance companies do not provide a cashless facility. Also, there can be times when you need to get treated at a hospital that does not fall in the list of network hospitals of the insurer. In such cases, you will have to pay for all the hospitalization costs and claim reimbursement later. Here are some things that you need to keep in mind:

  • Before paying the bill ensure that all the details are correct. Errors in the bill can cause unnecessary delays in the claim settlement process.
  • Typically, the documents required to be submitted along with the claim form include:
    • Claim form (duly filled and signed)
    • Copy of the policy or the insurance card
    • Discharge card from the hospital
    • A medical certificate signed by your doctor
    • All original bills and receipts
    • All pathological reports
    • The investigation report, etc.
  • You need to submit all these documents as soon as you are discharged from the hospital. The insurer might have specific timelines for submission. Ensure that you adhere to them.
  • Once the insurer receives all the required documents, your claim is reviewed, and on being approved, you receive the credit within 20-30 days from the time your completed application and documents reach the insurer.

If you don’t receive a response from the insurer within the said timelines, then you can approach the Insurance Ombudsman for redressal. Ensure that you check the complete claims process before purchasing a health insurance policy. Also, ensure that you get a detailed list of diseases and ailments covered under the policy. If you are purchasing a policy during the current pandemic, then ensure that you opt for reliable insurers like Tata AIG who offer health insurance for COVID-19. 

Summing Up

Before you buy the policy, research your options, and look for insurers with a simple claim settlement process and a high claim settlement ratio. Always read the fine print and clear all doubts before signing the dotted line. Remember, most dissatisfied insurance customers are those who have had a problem with their insurer while settling their claims. Hence, ensure that you check all details well.