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How To File Health Insurance Claim [2024]

If you unfortunately have an accident that requires a lot of money then what will you do? In situations like these a health insurance comes into play. With an health insurance is one of the type of insurance that helps the policy holder, by covering the medical expenditure like hospitalization charge, medine bills, etc. With a health insurance claim you can get all these healthcare financial help quickly.

The main purpose of a Health insurance plan is to remove the sudden financial burden from their policy holders and to provide their policy holder to give them peace of mind and let them focus more on their well being.

With a health insurance plan, policy holder has to pay a premium monthly or annual cost, and upon claiming the health insurance the company covers the cost of the policy holder like hospitalization charges, doctors visit, medication bills, etc.

How do you file a Health Insurance Claim?

Health insurance plans provide the additional benefit of cost free treatment and coverage of all the medical expenses of the policy holder by the insurance company. 

The policy holder can make a health insurance claim for the expenses incurred in accordance with the maximum sum insured of insurance coverage for health.

How do you file a Health Insurance Claim?

There are 2 types of health insurance claim procedures:

  • Health Reimbursement Claim
  • Cashless Claims

We will understand each of health insurance claim procedure briefly one by one.

Health Reimbursement Claim

Select the hospitals that are mentioned in the insurance networks, for treatments that are offered at the hospitals outside of the network, the policy holder have to make a claim for reimbursement of the cost of treatment. 

  • Firstly, all you need is to contact your health insurance company and provide them all your necessary details. Then gather all the medical bills, documents all the things that are needed when you request for the Reimbursement Claim.
  • Then you will have to fill the reimbursement form online or offline and submit that reimbursement form along will all your medical document to the insurance company
  • And upon getting your claim approved you will get your health insurance claim amount by cheque.

When the treatment is complete the insured has to pay the bill, get all of the documentation, and then submit a claim with the insurance company or TPA to receive reimbursement.

Cashless Claims

If the treatment is received at a hospital that is a network or a cashless hospital, the patient will be able to use cashless treatment. After the treatment has been completed, the insurance company pays the cost in full with the institution.

How do you file a Health Insurance cashless Claim

In the case of reimbursement as well as cashless claims, the procedures for planned and emergency hospitalization can differ according to the following guidelines:

In the event of Planned Hospitalization

  • If you plan to go to the hospital it is necessary to notify the insurance company at least 48 hours or 3 days before the procedure, Inform your Third Party Administrator(TRA).
  • Then you can file a cashless request at the hospital.
  • Submit the form filled out along with all the medical documents to the Third Party Administrator (TRA). Once you have the TPA’s approval, you are able to apply for reimbursement as well as cashless claims upon submission of the claim form.
  • Also, make sure to submit other documents, such as medical bills discharge summaries, reports, and so on.
  • When the approval is given when the approval is granted, the amount for the claim will be paid by the insurance company in the case of reimbursement claims.
  • In the case your form gets dissapproved you can file for reimbursement.

In the event of claims that are not cash-based the hospital bill will be directly paid by the insurer.

In the event of Emergency Hospitalization

  • In the case of an emergency hospitalization, you must inform the Third Party Administrator (TRA) or the insurance company within 24 hours of being hospitalized.
  • Bring your health card to the hospital.
  • Complete the pre-authorization form in order to receive TPA approval for hospitalization in an emergency for cashless claims.
  • If the insurer is approved, it will settle the claim directly with the hospital in the network.
  • If you don’t receive Third Party Administrator (TPA) approval, you will be required to file to be reimbursed later.
  • Send all documents required such as charges for hospitalization, discharges, etc.,
  • The amount claimed shall be paid to you.

Documents Required To Submit for the Health Insurance Claim Reimbursement

If there is an admission to a hospital, the owner of the policy has to present certain documents in order to claim Health Insurance Claim Reimbursement, in the following order:

Documents Required To Submit for the Health Insurance Claim Reimbursement
  • Card for discharge issued by the network hospital or hospital
  • In-patient hospitalization invoices that have been signed by the insured to prove authenticity
  • Medical prescriptions from doctors and bills from stores
  • Claim-form that has the signature of the insured on it
  • Report of an investigation that is valid
  • Disposables and consumables as prescribed by the doctor with full information
  • Doctors’ consultations and bills
  • Copies of the insurance policies from prior years, and the current year’s policy/copy of ID Card issued by TPA
  • Other documents (s) requested by the TPA

Conclusion

In conclusion, health insurance policy helps you in your difficult situations if you are surrounded by medical condition in need for financial support to full fill your medical bills like hospitalization charge, doctors visit, medication bills, etc.

If you have your health insurance policy you can always claim that whenever you are in need of financial support to cover your expensive medication costs. Just all you need is to file your health insurance claim. There are two ways to files an health insurance claim that are Health Reimbursement Claim and Cashless Claim.

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