How to Fill a Health Insurance Claim Form?

A health insurance claim is a request sent by a policyholder to an insurance company to get compensation for medical expenses. Every insurer has its own established set of processes through which policyholders can file medical claims. It involves the filing of a claims form, physical or online, along with supporting documents, which are verified by the insurance company before it compensates the expenses.

Health insurance claims can either be cashless or reimbursement. Cashless claims let you avail of treatment at a network hospital without requiring any upfront payment. On the other hand, a reimbursement claim involves paying for medical bills on your own and seeking compensation for them later. The expenses that an insurer will cover depend on the terms and conditions outlined in the policy document.

Before you buy a medical insurance policy, make sure that it provides a seamless claims filing process, timely settlements and the cashless claims facility. At TATA AIG, we offer online cashless settlement at any hospital across the country and a network of 12,000+ cashless hospitals for quick and seamless settlement.

The following are the two main types of health insurance claims in India you should learn about in detail:

Cashless Claims

In a cashless claim, the insurance provider directly settles the medical bills of the insured person with the hospital. This allows the policyholders to get medical treatment without paying any cash to the hospital, hence the name. Generally, cashless treatment is offered at network hospitals which are partnered with the insurance company.

To seek cashless treatment, the insured person needs to inform the insurer first and get pre-authorisation. Upon admission to the hospital, they need to show the cashless health card and policy documents and file a health insurance claim. After verification, the insurer will settle the bill with the hospital, subject to the terms of your cashless health insurance policy.

Reimbursement Claims

In a reimbursement claim, the insured person pays for their own medical expenses out of their own pocket and gets reimbursed by the insurer later. Alongside the claim request, the policyholder must submit bills, prescriptions and payment receipts to provide evidence for their treatment. Upon verification, the insurance company will credit the reimbursement directly to the policyholder’s bank account.

Many insurance companies offer the reimbursement option for getting treatment at out-of-network facilities or for situations where getting a cashless claim is not possible. As reimbursement claims are filed after treatment, their settlement generally takes longer than cashless claims.

Before you file a medical claim, here are the most important prerequisites you should know about:

• Make the Claim Intimation: Whether you want to get a planned treatment or deal with a medical emergency, you must inform your insurer within the stipulated deadlines. For planned hospitalisation, insurers typically require prior intimation 48-72 hours before your admission, while for emergencies, you need to inform within 24 hours of getting hospitalised.
• Check the Network Hospitals: Before you select a medical insurance plan, check the insurer’s list of cashless network hospitals. Look at the network size and if it includes reputable hospitals where you live and work. Also, consider if the network includes multispecialty hospitals and specialist centres like eye hospitals, ENT hospitals, neurology centres, and diagnostic centres.
• Read the Policy Terms and Conditions: Read through the fine print of the policy documents of your chosen plan. Pay special attention to exclusions, coverage limits, waiting periods, co-payment and deductible clauses, etc. This will help you understand the claim requirements.
• Know the Claim Process: You should thoroughly check your insurer’s claim process before filing claims to avoid mistakes during an emergency. Learn the filing process, policy terms and documents required, and note down the insurer’s emergency and customer support helplines. You can also inform a close friend or family member about the admission process.
• Have the Necessary Documents Ready: Depending on your insurer’s claim process, you will need documents like your health insurance card, policy documents, diagnosis test reports, prescriptions and payment receipts. You can keep all necessary documents ready in a file to have them on hand when you file a claim.

Insurance companies have different processes for planned and unplanned cashless treatment and reimbursement claims. Here, we have described the different claim processes for medical insurance plans:

Planned Hospitalisation- Cashless Claim

If you have decided to get admitted to a hospital for a planned treatment, follow these steps:

Step 1: When you need medical treatment, inform your insurance provider at least 48 hours in advance of your planned hospitalisation. You can file a cashless claim form via email, letter or the online platform of your insurer.

Step 2: Once the insurer has received your claim request, they will process your claim and send a confirmation letter. This letter remains valid for a certain number of days.

Step 3: On the day of your hospital admission, contact the bill counter or helpdesk with your health insurance card and confirmation letter.

After your discharge, the insurer will settle your bills directly with the hospital and cover all medical expenses within the limits of your chosen policy.

Unplanned Hospitalisation- Cashless Claim

In case you have a medical emergency and get hospitalised, follow these steps to get cashless coverage:

Step 1: You can contact your insurer directly using their contact details or get help from the hospital TPA agent. Make sure to inform your insurer within 24 hours of getting hospitalised.

Step 2: Fill out and submit the cashless form along with your insurance card, policy papers, identity and address proof, etc. You can check the steps on how to fill out a medical insurance claim form below.

Step 3: Once the insurer receives your claim, they will process your request and send an authorisation letter for your treatment. Post-discharge, the insurer will settle all bills under policy limits.

Reimbursement Claim

Step 1: Once you have received your medical treatment, sign the hospital bill after checking all financial details. Then, ensure you collect all important documents after your discharge from the hospital.

Step 2: Learn how to fill a medical claim form (online or physical reimbursement claim form) with the required details, discussed below. Also, make sure to attach photocopies of all relevant documents, including bills, receipts and prescriptions. You can submit these to your insurer or a TPA agent.

Step 3: It will take some time to process your claim form and all submitted documents. Once that is over, the insurer will either accept or reject your claim and send the reimbursement to your bank account.

Most insurance companies allow multiple ways to file health insurance claims, including digital and physical methods. While online health insurance forms are recommended, you can file physical forms in certain situations, including unplanned hospitalisation, treatment at non-network hospitals, technical issues with the app, etc. Read our guide on how to fill out a claim form for health insurance:

Step 1: Get the Health Insurance Claim Form

You can get a copy of the claim form from the insurer’s official website or a physical copy at the hospital where you are admitted. Ask a TPA (third-party administrator) at the hospital if you need a new form or help regarding claim filing. You can initiate a claim online for a quick and seamless process. Check out how to fill out a medical claim form and ensure you have the right form before filling it out.

Step 2: Fill out the Form

A health insurance claim form has two parts- Part A, which the policyholder fills out, and Part B for the hospital. Fill in all the required details in Part A, including full name, address, policy number, insurer’s details, contact details, insurance history, etc. Then, enter your hospital details and hospitalisation expenses from bills and reports.

Step 3: Attach the Required Documents

For cashless claims, you only need to submit your health insurance card and policy papers. Speak to the TPA agent at the hospital to know if you require additional documents and identification. For reimbursement claims, gather multiple documents upon discharge, including discharge certificate, medical bills and test reports.

Step 4: Make a Copy

Create photocopies of all support documents to submit your claim form. After filling out and signing the form, also create a copy of the form for your reference and backup in case you lose the documents.

Step 5: Review and Submit the Form

Cross-check the details and submit your claim form to file a mediclaim. For cashless claims, submit the form at the TPA desk at the hospital. For reimbursement claims, mail the form and copies of supporting documents to the insurer’s office address. You will get a reference number, which you can use to track your claim status.

Depending on your chosen insurer and type of claim (cashless or reimbursement), you will need to submit some of the following documents to file a health insurance claim:

• Duly filled out and signed claim form
• Your health ID card
• Insurance policy documents
• Medical certificate signed by a doctor
• Original hospital final bill
• Discharge summary and certificate
• Pathological reports, including X-Ray scans, CT scans and diagnostic tests
• All original medical bills and prescriptions
• FIR (First Information Report) and MLC (Medico-Legal Certificate) for accident-related claims
• Payment receipts and NEFT details for reimbursement claims
• Cancelled cheque, bank statement or passbook copy
• KYC documents (including identity and address proof) for claims above ₹1 lakh

Here are some common mistakes to avoid when filing health insurance claims:

• Non-Disclosures and Wrong Entries: Providing incomplete or incorrect details related to your health insurance claim is the most common reason for rejection. Do not hide facts, such as your medical history or pre-existing diseases, when filing claims.
• Mistakes in Hospital Details: A claim form requires you to submit several important details, including treatment expenses, bill number, hospital details, etc. It’s easy to make mistakes if you don’t take the help of hospital staff.
• Incomplete Medical History: If you have a history of prior illnesses, the insurer will want you to share records and details with your doctor. Incomplete or mismatched details may lead to claim rejection.
• Forgetting Policy Limits: Every insurance policy comes with certain limits. Health insurance plans have waiting periods, during which no medical coverage is offered and limits like co-payments and deductibles, which increase out-of-pocket expenses. Forgetting these limits may result in rejection.

You can file a health insurance claim via online or offline modes. However, you must take extra precautions while filling out a health insurance claim form. Any mistake or error can lead to the rejection of your claim, and you may have to bear the entire expense. To avoid such situations, ensure to have a thorough understanding of the claim process and terms of your chosen policy.

At TATA AIG, we ensure a smooth claim settlement process for health insurance policies. We offer multiple channels for processing claims, including a web portal, mobile app, claims page and 24/7 helpline (022-6489-8282). With a cashless network of 12000+ hospitals, extensive coverage options and instant processes, ours is one of the best health insurance in India.

For individuals aged 60 years or above, TATA AIG’s senior citizen health insurance is a well-suited option that offers tailored coverage to meet their healthcare needs. It comes with unique benefits like high-end diagnostics cover, wellness services, home nursing services, compassionate care and home modification for disability care.