Health Insurance Claims

Basically there are two types of process in Health Claims – Cashless claims & Reimbursement claims.

Cashless Claims

  • For claim on cashless basis, the insured should get admitted to network hospitals of Third Party Administrator (TPA)/Insurance Company.
  • The pre-authorisation form along with necessary documents like investigation report, previous consultation paper (if any),Cashless ID, Photo ID proof, residence proof etc. will be mailed by the hospital to the TPA/Insurance Company.
  • The TPA will review the claim request and accordingly approve, query or reject the same as per the policy terms and conditions.
  • TPA will settle the claim as per policy terms and conditions with the hospital after completion of necessary formalities.

Reimbursement claims

  • For claim on reimbursement basis, the insured should get admitted to any Network/Non Network hospital. The claim should be intimated to the TPA/Insurance Company to get the claim number within stipulated time as per the policy terms and conditions.
  • After getting discharged from the hospital, the insured should collect all the original documents from the hospital and submit the same to the TPA/Insurance Company along with the claim form and policy copy within stipulated time as per the policy terms and conditions.
  • The TPA/ Insurance Company will review the claim request and accordingly approve, query or reject the same as per the policy terms and conditions.
  • For approved cases, Settlement letter is mailed/couriered to the insured/proposer and Payment is released through NEFT/RTGS by the insurance company.
  • For queried cases, query letter is sent to the client requesting for additional documents/information. Reminders are sent to the client and if the requested documents are not received after reminders, the claim closure letter is sent to the insured.
  • For rejected cases, rejection letter is sent to the insured mentioning sufficient reasons as per the terms and conditions of the policy.

Documents for Claim

  1. Copy of the policy
  2. Copy of the Intimation Letter / Mail / Intimation No
  3. Duly filled & signed claim form
  4. Original discharge card / Discharge Summary duly signed by treating doctor and with hospital stamp.
  5. Original hospital bill with break-up details with serial no. duly sealed & signed.
  6. Original pre-numbered hospital payment receipt duly sealed & signed,
  7. Original prescriptions,
  8. Original pharmacy bills (please make sure patient name is mentioned on the bill)
  9. Original advance paid receipt if any
  10. Original investigation reports along with original bills & payment receipts for the investigations done within & outside hospitals.
  11. Original consultation papers, if any
  12. All Imaging Films, ECG Strips, Doppler / Angiogram CD etc.
  13. Hospital Registration Certificate (in case of a unknown small hospital)
  14. Any other original documents related to the claim.
  15. MLC/FIR in case of Accident cases.
  16. The copy of the cancelled cheque of the policy holder / Employee in case of corporate client where in claim is payable to employee
  17. If employee has availed a cashless but if the same is not utilized letter from the hospital mentioning the same.
  18. Copy of Valid Photo Id Proof of the patient & Policy holder / Employee in case of corporate client.
  19. Address Proof of Policy holder / Employee in case of corporate client if the claim is more than 1 lakh.

  The above is a brief summary of the claims process and documentation, and not to be taken as exhaustive. The surveyor/Insurer/TPA may call for additional requirements on case to case basis.