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Health Insurance Claim
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Health Insurance Claim Everything You Want To Know
Types of Claims – Cashless or Reimbursement
With cashless claim settlement, the insurer directly pays the hospital bills if the treatment is done at one of their network hospitals. This means that the insured must choose a network hospital to avail of cashless treatment.
In reimbursement claims, you can choose a hospital outside the insurer's network. The insured pays the hospital bills during discharge and then requests the insurer to reimburse the expenses later.
Kinds of Hospitalisations Under Health Insurance Claim
This occurs when the doctor advises hospital admission for a specific illness or procedure, and the insured notifies the insurer beforehand.
This happens when a patient is admitted urgently for reasons like an accident, heart attack, or other medical emergencies. The insured informs the insurer within 48 hours of hospitalisation.
Factors Influencing Health Insurance Claim Settlement Ratio
This is calculated by dividing the total claims settled by the insurer against the total claims received, including outstanding claims from the start of the year. A higher ratio indicates better performance.
Look for insurers with a consistent claim settlement ratio over the past five years as it shows reliability. Choose a company with a higher or consistent ratio for your health plan.
Consider the number of claims that an insurer has received during a financial year when selecting a provider.
The Insurance Brokers Association of India (IBAI) publishes the Claim Settlement Ratio of all insurance companies in India (both public and private) every year. You can access the report on the IBAI portal to identify the best companies with medical claim settlement ratios.
Steps for Cashless/Reimbursement Claims
Claim enquiry and assistance: Visit the Paybima store near you and connect with your relationship manager or call the toll-free number <1800 267 6767>. We will assist you with the steps for raising the claim.
Verify the type of claim: cashless or reimbursement.
Inform the TPA or the insurance company as per the timeframe for cashless or reimbursement respectively.
Submit the required documents as per the type of claim – cashless or reimbursement.
3 days prior to admission
- Choose a hospital: For a cashless claim the Insured or a family member has to choose a hospital from the network as mentioned in the policy document/insurer’s website
- Inform the TPA: The insured or a family member has to visit the TPA counter of the hospital 2-5 days prior to the admission date.
- Document submission: At the counter, submit the health ID card, policy copy, Aadhar card copy and diagnosis reports/advise note of the treating doctor.
- Document inspection: The insurer/TPA will inspect all the documents and issue an initial authorisation letter to the hospital. The hospital may ask for a nominal refundable security deposit as per their management
At the time of discharge, the insurance company will give final authorisation against the hospital bills, which excludes non-consumables, instruments, and various charges as per IRDAI guidelines.
Even if the cashless claim gets denied during the cashless claim process, the insured can submit the claim for reimbursement. The respective TPA verifies the claim based on policy terms and conditions and inspects documents submitted and gives their final decision.
3 days prior to admission
- Choose a hospital: For a cashless claim the Insured or a family member has to choose a hospital from the network as mentioned in the policy document/insurer’s website
- Inform the TPA: The insured or a family member has to visit the TPA counter of the hospital 2-5 days prior to the admission date.
- Document submission: At the counter, submit the health ID card, policy copy, Aadhar card copy and diagnosis reports/advise note of the treating doctor.
- Document inspection: The insurer/TPA will inspect all the documents and issue an initial authorisation letter to the hospital. The hospital may ask for a nominal refundable security deposit as per their management
At the time of discharge, the insurance company will give final authorisation against the hospital bills, which excludes non-consumables, instruments, and various charges as per IRDAI guidelines.
Even if the cashless claim gets denied during the cashless claim process, the insured can submit the claim for reimbursement. The respective TPA verifies the claim based on policy terms and conditions and inspects documents submitted and gives their final decision.
Even if the cashless claim doesn't get through in time during discharge or if the insured needs to be admitted to a non-network hospital, you can file for a reimbursement claim.
- Inform about the hospitalisation: Inform your insurance company/TPA through the toll-free number or connect with Paybima store, within 48 hours of admission.
- Download the reimbursement claim form: The claim form is available on the insurer's website/TPA,
- Submit the following documents
- Claim Form - Filled and signed by the insured – Part A
- Claim Form - Filled and signed by the hospital – Part B
- Original discharge summary/discharge card
- Original payment receipts (advance receipts & final bill payment receipts)
- Original bills of doctors’ consultations and prescriptions
- Bills and receipts of all investigations (MRI, Xray, Pathology, etc.)
- Original pharmacy bills
- Copy of in-patient records
- Copy of age proof (driving license / PAN card/Aadhar card/ passport)
- Personalised cancelled cheque (name printed) of the proposer or bank passbook copy
- Prescriptions and hospital bills 30 days pre- and 60 days post-hospitalisation. In such cases, the expenses for post-hospitalisation can be claimed after 60 days.
- Attested hospital registration certificate
- ** Depending on the specific case, additional documents may be asked
- Inspection of documents: The insurance company/TPA will inspect to see ff all the documents submitted are in order, settle the reimbursement amount via electronic transfer within 10 to 15 working days.
Health Insurance Claim – How to Avoid Rejection
Here are some of the factors that could get your claim rejected:
If the insured claims for an illness that is not covered during the policy’s waiting period, it may get rejected.
A claim can also be denied if the pre-existing disease or treatment is not included in the policy.
Claims for treatment without immediate hospitalization in the OPD are not accepted.
Claims may be rejected if hospital admission is solely for evaluation purposes and not for treatment.
How to Claim Health Insurance with Multiple Insurers
To raise a claim with multiple health insurance plans from different insurance companies:Insured must notify all insurers within 48 hours before or after admission.
Insured must submit documents to the first insurer and settle the claim.
Insured must obtain attested copies of medical papers and bills, along with the settlement letter.
Insured must submit these papers (mentioned in step 3) to the second insurer/TPA.
The 2nd insurer will verify the claim and settle the balance amount.
How to Check the Status of Claim
Here are some of the options you can choose to check your health insurance claim status.
You can visit the nearest branch office of Paybima or your health insurance company with all the essential details regarding your policy.
You can also inquire about your health insurance claim status by calling our claims assistance number or your insurer’s toll-free customer care number at 1800-267-67-67 to speak with a customer executive.
You can also submit your health insurance policy number and other details by sending an email to support@paybima.com.
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