Health Insurance Claim Process Health Insurance Claim Process: Health insurance is most useful when a person is at their most physically and mentally vulnerable. Unfortunately, this is precisely when they are most vulnerable.

Over the past 10 years, I’ve not only handled numerous health insurance claims myself, but I’ve also helped hundreds of people. Some had their cashless claims rejected, others had their reimbursements delayed for months, and many simply couldn’t find a solution.

Friends, in this article, I am explaining the Health Insurance Claim Process from the ground up, step by step, without any agent language, without beating around the bush, I will tell you directly how to make an insurance claim.

What is a Health Insurance Claim?

When you or a family member falls ill and incurs medical expenses, a request is made to the insurance company to reimburse the expenses incurred. And the opportunity to use your deposited amount in an emergency is called a health insurance claim. This claim can be made in two ways:

Cashless Claim and Reimbursement Claim

Friends, let us further understand both the claim processes in detail.

• 3 Important Things to Understand Before Understanding the Claim Process

It is crucial to understand these three things before filing any insurance claim, otherwise the chances of the claim being rejected increase:

1. Waiting Period Every policy has a waiting period for certain illnesses. If a claim is filed during that time, rejection is almost certain. First, check the policy to see which illnesses still have a waiting period. Make the claim accordingly so that your file will not be rejected.

2. Network Hospital Cashless claim is possible only if the hospital is in the network of your insurance company, for example, suppose you are undergoing treatment in any hospital and If you file an insurance claim at this time and your hospital is not in the insurance company’s network, you will not get the claim and your file may be rejected.

3. Policy Terms Reading policy documents can be boring, but they can be your biggest shield during a claim. That’s why it’s crucial to read the policy document first to avoid any mistakes during a claim.

Type 1: Cashless Health Insurance Claim Process (Step by Step)

Cashless claim is considered to be the easiest and stress-free method, if done correctly.

Step 1: Network Hospital As soon as the doctor advises admission, first confirm: Whether the hospital is in your insurance company’s network or not and to know this information visit the insurance company’s website TPA (Third Party Administrator) Health

Step 2: Inform the Hospital Help Desk The hospital has an Insurance/TPA desk. Go there and tell them you want to make a cashless claim, and they may ask for some documents.

Step 3: Filling the Pre-Authorization Form This is the most critical step; certain documents are included in this form, such as patient information, illness details, estimated expenses, doctor’s signature, etc. The hospital submits this form directly to the insurance company or

अभी ऑफर में फॉर्म भरें 

 

Step 4: Waiting for Insurance Approval The insurance company now performs some fact-checks, such as the illness, policy coverage, and waiting period. Approval is usually granted within 2–6 hours (in case of an emergency).

Step 5: Treatment and Discharge After the treatment is completed: The insurance company pays the hospital directly. If there are any non-payable expenses, you have to pay them like: Registration charges, Extra consumables, Non-medical items

Real Life Experience (Cashless Claim) Once, someone I knew thought cashless meant the entire bill was free. But at the time of discharge, they had to pay ₹8,500 because: Some medications were not covered by the policy; a room upgrade charge was applied. This is where it becomes important to understand the policy.

Type 2: Reimbursement Health Insurance Claim Process (Step by Step)

When: The hospital is not in the network or cashless approval is not available Then a reimbursement claim has to be made.

Step 1: Hospital Admission & Payment Here you: Pay the entire expense yourself and keep all bills and documents, which will be useful when filing a claim later.

Step 2: Providing Claim Intimation As soon as treatment begins or after discharge: It is important to inform the insurance company, such as through a helpline, app, or email. Any further delay may result in the claim being delayed, so avoid any delay.

Step 3: Filling out the Claim Form The claim form includes: policy number, patient information, illness details, bank details, etc. Fill out this form very carefully; even a small mistake can cause delays.

Step 4: Submitting Documents Commonly requested documents: Discharge Summary, Final Hospital Bill, Doctor Prescription, Investigation Reports, Pharmacy Bills, Payment Receipts

Step 5: Claim Verification The insurance company verifies everything from your medical history and policy terms and conditions in the documents. This can take 15–30 days, after which your claim is approved.

Step 6: Claim Amount Credited If all goes well: The approved amount is transferred directly to your bank account. Common Reasons for Claim Rejection

In my experience, most of the claims are rejected due to the following reasons: Hiding pre-existing disease, Claim during waiting period, incomplete documents, Non-disclosure of medical history, Policy lapse\

My Opinion (Personal Experience & Honest Advice)

Health Insurance Claim Process Friends, in my opinion, health insurance isn’t just a policy, it’s a responsibility—for yourself and your family. But simply purchasing a policy isn’t enough: you need to understand its claims process. Not every word, but the essential terms you need to understand. I’ve seen people pay thousands in premiums, But they don’t spend 30 minutes understanding the policy. The result: regret at the time of the claim. If you’re reading this article carefully today, you’re ahead of 90% of people.

Final Thoughts

The health insurance claims process isn’t complicated, it’s made difficult. Misinformation and negligence. If you: provide timely information, keep complete documents, and honor the policy, the insurance company will also settle your claim honorably.

FAQ Health Insurance Claim Process

FAQ 1: Why do health insurance claims get rejected?

Claims are commonly rejected due to non-disclosure of pre-existing diseases, claiming during the waiting period, incomplete or incorrect documents, treatment not covered under the policy, or policy lapse due to unpaid premiums.

FAQ 2: Is it mandatory to inform the insurance company before hospital admission?

Yes, for planned hospitalizations, prior intimation is mandatory. In emergency cases, the insurer should be informed within 24–48 hours of admission to avoid claim issues.