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How to make a health insurance claim that ensures you get back the claimed amount?

Posted on 21 Aug 2022
Author: Sayan Sircar

Tags: Health Insurance ; Insurance ; Step by step

7 mins read
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This article shows the steps to correctly file a health insurance claim so that it gets processed quickly and you get back as much as possible.

How to make a health insurance claim that ensures you get back the claimed amount?

📚 Topics covered:

Background of Health insurance
The role of the third party administrator (TPA)
Type 1: Cashless claims
- Pre-procedure process for cashless
- Post-procedure process for cashless
Type 2: Reimbursement claims
- Pre-procedure process for reimbursement
- Post-procedure process for reimbursement
Corporate or personal cover for claim

This article is a part of our detailed health insurance article series. Ensure you have read the other parts here:

Frequently asked questions (FAQs) on Cashless Everywhere facility in health insurance

This article gives you a list of common questions and their answers on the concept of “Cashless Everywhere” introduced for health insurance.
What are top-up and super-top-up health insurance policies? Do you need either?

This article talks about deductible-based health insurance plans like top-up and super-top-up and shows which one you should buy and why.
How to make a health insurance claim that ensures you get back the claimed amount?
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Health insurance: what, why, how much to get and from where?

This article explains why health insurance is important, how to choose one that suits your needs, the tax benefits and where to buy it from.
A health insurance premium fund: who needs it and why

This article shows you a better alternative to paying premiums every month or quarter as well as manage when premiums increase over time.

Background of Health insurance

The role of the third party administrator (TPA)

Before making a claim, it is essential to understand the role of the third-party administrator (TPA).

TPA is an intermediary who the insurance company appoints to process the claims of the insured person

The TPA takes the claim documents and other details to the insurance company for processing. However, they do not have authority over approval or rejection of the claim, which is the sole prerogative of the insurer.

If your health insurance company does not offer the services of a TPA, it means that they have an in-house claims processing team handling your claim.

There are two different types of health insurance claims. We will cover both below.

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Type 1: Cashless claims

A cashless claim means you do not pay the bill or pay only a tiny part at the time of discharge from the hospital. The following conditions must be true to ensure that cashless claims are possible:

the hospital must be a network hospital of the insurer or TPA
the insurance company should have been made aware of the procedure if planned, and a pre-operative authorisation should be obtained from them

Pre-procedure process for cashless

You need to locate a network hospital, typically from the list on the insurance company website or by contacting them. Ensure that you share a list of network hospitals or the process of locating one with your family if you cannot make a choice yourself.

Once admitted at the network hospital, inform the insurance company and send them a pre-authorisation form for approval. For planned procedures, you should inform the insurer before admission.

Once the hospital sends the form, it will come back as approved, and you can proceed with the treatment.

Post-procedure process for cashless

At the time of discharge, we will cover two main steps now.

You must review and authorise all bills so that you can both consent to them and pay for any items/services/expenses not covered under your policy.

The insurer will then receive the bill from the hospital and pay them directly. Since the claim is pre-approved, this process should be fast.

Type 2: Reimbursement claims

A reimbursement claim is one where you pay the entire bill to the hospital and then claim it from the insurer. How much of the total bill will be reimbursed will depend on the terms of the policy, hospital and procedure, level and type of service (e.g. AC/non-AC rooms), procedure type and quality of documentation.

Note: It is imperative that you, as the insured person and related family members, be either intimately familiar with the claims process or have the support of a capable TPA or health insurance agent. Being neither will lead to huge losses if the claim is not presented correctly.

Pre-procedure process for reimbursement

A reimbursement claim, typically, will be for a procedure at a non-network hospital. This hospital selection can be involuntary, in case of an emergency where you are rushed to the nearest hospital or even by choice. Even in such cases, it is vital to inform the insurer as soon as possible.

Post-procedure process for reimbursement

At the time of discharge, collect the discharge summary, prescriptions and bills for submission to the insurer along with an adequately filled claim form. This vital step should be performed with adequate care and due diligence.

You need to obviously pay the entire hospital bill in full at this time to go home. Therefore a well-funded emergency fund shines here. Refill the emergency fund once you get the claim from insurance.

Once the insurance company receives the claim details, it will be processed, and they will send the amount to you by cheque or bank transfer.

Since the claim amount is reimbursement of an already occurred expense, it is tax-free in the hands of the insured person.

Corporate or personal cover for claim

This situation arises when you have both covers active at a time.

If you are choosing between a corporate health cover and your personal cover for making a claim, always choose the corporate one so that no claim record in the personal cover stays intact. After all, the corporate cover will cease once you switch jobs or retire but the personal cover will stay for life.

You will be able to get good customer service as well from your company HR and the relevant TPA.

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