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How to Reimbursement Claim on Health Insurance?

  • Author :
  • TATA AIG Team
  • Published on :
  • 12/12/2022

A smooth claim settlement process in health insurance is not merely convenient but necessary. When you are dealing with a health concern, you would like to focus on your recovery instead of worrying about paying for the treatment expenses and the cost of hospitalisation. This is why insurance providers strive to ensure a seamless health insurance claim process. However, for your insurance provider to enable smooth medical claims processing, you will have to help with certain aspects. And one way to ensure this is to be informed about the healthcare claims processing.

The first thing to check is whether you have opted for cashless claim settlement or are seeking a medical claim reimbursement. Let’s begin with understanding the difference between the two.

Types of Claim Settlement Process in Health Insurance

A health insurance plan is a financial safety net that is designed to assist you in seeking medical treatment if your health fails you. Since problems don’t inform you before they arrive, you may have to raise a claim against your health insurance policy for planned or unplanned hospitalisation. There are two kinds of claim settlement processes: cashless claim settlement and medical claim reimbursement.

  • Cashless Claim Settlement Process

As the name suggests, with a cashless settlement of the claim, the policyholder can avail of the healthcare services in a cashless manner. However, for cashless claims, the policyholder needs to ensure that they are seeking treatment exclusively at the hospital that is linked with their insurance provider. At a network hospital, the insured member only has to provide the hospital desk with the health card issued by the insurance company to receive cashless claims. This way, the insured member need not pay a penny from their pocket as the entire medical bill is settled directly by the insurer with the hospital.

  • Medical Claim Reimbursement

There can be certain occasions wherein you might have to seek medical treatment at a hospital that is not a part of your insurance provider’s network. In case of emergency hospitalisation, this may happen because an individual is compelled to seek treatment at the nearest healthcare facility. Whereas for planned hospitalisation the reason could be that you prefer to seek treatment with a specific doctor who works in a particular hospital that is not linked with your insurance company. In these scenarios, the individual will have to pay for the treatment from their pocket and then get the bills reimbursed. The amount that you pay at the hospital is later reimbursed under your health insurance policy once you submit all the necessary documents.

It is important to note that while raising a reimbursement claim, the policyholder will have to be careful about the coverage of the treatment and the associated expenses under their health insurance plan. For instance, if you are diagnosed with a critical illness that is not covered under your regular health insurance policy, you may have to bear the cost of treatment from your pocket. Critical illness insurance enhances the scope of your health insurance to provide you with suitable coverage if you suffer from a critical ailment. Now that we understand the different types of healthcare claims processing, let’s understand how the difference between the two affects the insurance holder.

How Does the Type of Claim Affect the Policyholder?

The table below illustrates how the difference between cashless claims and reimbursement claim affects the policyholder:

Cashless Claims Reimbursement Claims
Since the cashless claim is settled directly with the hospital by the insurance provider, it is a quicker and more convenient option. For reimbursement claims, the insured member has to pay from their pocket and then get the medical bills reimbursed, which increases the processing time
For cashless claims, the empanelled hospital is responsible and obligated to share all the documents with the insurance company. For a reimbursement claim, the policyholder will need to look after all the necessary bills and documentation to be shared with the insurance company.
Since the hospital is linked with the insurance provider, the claim is settled faster As the hospital is outside of the insurer’s network, the claim will be thoroughly investigated before settling

Steps to Raise a Reimbursement Claim

To ensure a seamless reimbursement health insurance claim process, here are the steps to follow:

  • Step 1: Before you sign your medical bill in the hospital, it is critical to ensure that all the details are accurate. Don’t rush to sign the bill. Verify the details mentioned in the bill, as any discrepancy directly influences your claim settlement.

  • Step 2: Ensure that you submit all the essential documents to your insurance provider:

  • Duly filled claim settlement form

  • Copy of your health insurance plan or the insurance card

  • The medical certificate with the doctor’s signature

  • Pathological reports

  • Discharge card from the hospital

  • Original copies of the medical bills and receipts

  • Original bills of the pharmacy

  • Investigation report (if applicable)

  • MLC/FIR copy in the case of an accident claim

  • Bank details to credit the claim amount

  • Duly filled CKYC form if the medical bill exceeds ₹1 lakh

In case all these documents are not immediately available, the policyholder will have to collect them later and then submit them to the insurer.

  • Step 3: Once all the necessary documents have been submitted, the policyholder can relax and wait for the claim to be settled. It may take up to 21 days to settle the claim. During this time, the insurance company may call you if it has a query or if the claim is rejected.

Knowing all the steps involved in raising a claim is the best way to ensure seamless medical claims processing.

The Importance of Health Insurance with Critical Illness Cover

Our lifestyles have undergone great changes. A sedentary lifestyle paired with insufficient nutrition contributes to several illnesses and health ailments. Add to this the rising cost of medical expenses, and it is enough to stress an individual. Fortunately, with a comprehensive health insurance policy, many of these worries can be put to ease. But what happens when your health insurance does not cover an illness?

There are certain health ailments, such as cancer, cardiac stroke, paralysis, etc., which are not covered under regular health insurance. This highlights the importance of critical illness insurance.

In Conclusion

Critical illness insurance can protect your finances from bearing the burden of expensive medical treatment. Another of its prominent benefits is that it affords the policyholder peace of mind. The critical illness insurance by Tata AIG covers an extensive range of critical illnesses to enhance the coverage of your basic health insurance. It comes with beneficial features that will assist the policyholder focus on their treatment without worrying about a hit to their finances.

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