Health Insurance Claims Process
Health insurance claim process with detail documents list & step by step procedure for cashless & reimbursement health claim. Now check online with TATA AIG insurance.
Filing an insurance claim is never as easy as it seems- unless you follow this process
Buying insurance is seamless. However, claiming insurance can be challenging. All the documentation and processes can seem lengthy and confusing, but it's essential to understand them beforehand. To make it easier for you, here’s a breakdown of the process of making a health insurance claim.
** Health insurance is claimed in two ways:**
When an insurance company provides a cashless claims facility, it means that in case of hospitalisation, you don’t need to pay anything for the covered expenses; the insurer will directly pay the hospital on your behalf. However, such a facility is only available in a certain network of hospitals, which have agreements with the insurance company. List of Network Hospitals are available on TPA (third-party administrator) website.
If you’ve set a date for a certain treatment or surgery and are aware of hospitalisation beforehand, it’s planned hospitalisation. In such a case, the following steps have to be adhered to:
Step 1: Inform the insurer The cashless claim form has to be submitted to the insurance company via email or letter, at least five days before the treatment.
Step 2: Wait for the letter Once the insurer has received your cashless claim form, they will notify the hospital and provide you with a confirmation letter. Cashless claim confirmation letter is valid for seven days from the issued date.
Step 3: Submit the letter On the day of admission, you need to submit the health card and confirmation letter.
Your job here is done. Your insurer will directly pay the medical bills to the hospital.
When the hospitalisation is sudden and unexpected, like in case of an accident, it is emergency hospitalisation. In such a case, the following steps have to be adhered to:
Step 1: Inform the insurer
The insurance company or their TPA (third-party administrator) should be informed within 24 hours of hospitalization to generate Claim Intimation/ Reference Number. Documents to be produced to avail the Cashless services are Listed Below.
- Insurance Card
- Policy Copy
- Customer ID Proof with Photo
- Customer Address Proof.
- Duly Filled CKYC Form if Claimed amount is above Rs 1L.
Step 2: Further documents
The hospital needs to fill the cashless claim request form and submit it to the insurance company.
Step 3: Authorisation letter
After the submission of the cashless claim form, the insurer will issue an authorisation letter to the hospital.
In this case as well, your insurer will directly pay the medical bills to the hospital. In case of rejection, you will be notified about the same via a letter on registered Mobile Number and E mail ID.
Reimbursement Claim Process
In case the insurer does not provide cashless claim facility, or if the hospital is not a part of their network hospitals, you’ll have to pay the medical bills at the time of hospitalisation. The insurer will later reimburse you for the medical bills.
In case of the reimbursement claim process, the following steps have to be adhered to:
Step 1: Verify the details
Before signing on the bill, verify whether the details are accurate. This is critical as any discrepancy over here could impact the claim process.
Step 2: Collect the documents
Here is a comprehensive list of the documents that may be required:
- Duly filled and signed Claim form - Link to Download Claim Forms
- Insurance Card or Policy Copy
- Medical Certificate signed by the doctor
- Pathological reports like X-ray reports
- Hospital discharge card
- Original Bills and receipts
- Original Pharmacy bills
- Investigation report, if any
- FIR / MLC Copy (in case of an accidental claim)
- NEFT Details to credit Claim Settlement
- Duly Filled CKYC Form if Claimed amount is above Rs 1L.
Step 3: Follow up for documents
Some of the above listed documents may not be available immediately, and you might have to go back after a few days to collect them.
Step 4: Submit the documents
As soon as you are discharged, you can submit all these documents to the insurer or the designated TPA, depending on your insurer’s process.
Step 5: Wait for payment processing
Once the documents reach the TPA or the insurer, they will be reviewed. It takes about 21 days from the time the documents reach the TPA to the date of processing the payment.
If the insurer or TPA rejects the claim or has a query, then you would be notified about the same. Complaints-
If you are not satisfied with our services and wish to lodge a complaint, Kindly
- Email the customer service desk at email@example.com
- Call our 24X7 Toll Free Number 1800 266 7780.
- Senior Citizens can call our dedicated line at 1800 22 9966
If you do not receive a response from us within one month or not satisfied with our reply, you may approach the nearest Insurance Ombudsman under the Insurance Ombudsman Scheme as per the Redressal of Public Grievances Rules,2017.
Please refer respective Product Policy Copy for the complete details and additional information.
Important things to remember: Policy document of the current insurer Copy of insurance renewal notice or previous 3 years' policy schedules.
l Self-declaration, if you hadn’t made any claims with your old insurer l If you had made claims with your old insurer, the claim details are required
At the time of a medical emergency, figuring out the claim process and documentation will be the last thing on your mind. However, that’s needed in order to benefit from your health insurance cover. Hence, it’s important to #ThinkAhead and know the intricacies of the claim procedure beforehand and clear your queries if you have any.