Things to Remember While Filing a Health Insurance Claim

Filing a health insurance claim can be stressful if you are not sure about the process. To make it smoother, you need to be aware of certain aspects that can impact your claim’s approval. Whether it is understanding your policy’s coverage or making sure you have got the right documents, a little preparation can go a long way.

Here are a few simple, yet effective, tips to help you avoid common pitfalls and file your claim with ease:

Stay On Top of Your Policy Tenure

It is highly advisable to keep track of your policy’s expiry date to continue enjoying the coverage uninterrupted. You must renew the policy before the expiry date to ensure you get the desired financial assistance in case of an injury or illness. One of the best ways is to set a reminder a few days before the expiration, so you have buffer time to make the payment for renewal.

Be Aware of the Policy Coverage

Another crucial point to consider while filing a claim is the coverage offered by the insurance plan. Insurers offer various plans such as individual, family floater, critical illness and so on. While the primary purpose of each one is to provide you with financial assistance in case of emergency, the scope of coverage, expenses included and diseases covered may differ significantly. Thus, knowing the exact coverage ensures you do not file a claim for instances that are not covered, as it may lead to claim rejection.

You must read the policy documents carefully to understand the coverage and file a claim accordingly.

Thoroughly Read the Terms and Conditions

Understanding your policy’s terms and conditions is crucial when filing a claim. Even if you know the inclusions and exclusions, certain conditions may disqualify your claim. For example, if there is a waiting period or specific pre-approvals required, you need to be aware of them.

Make sure you understand eligibility factors, waiting periods and pre-approvals before you proceed with filing a claim. This clarity helps in streamlining the overall process.

Intimate the Insurance Company on Time

Whether it is a planned surgery or an emergency hospitalisation, notifying your insurance provider on time is essential. The time frame for informing the insurer about the incident or hospitalisation may range from 24-48 hours, depending on certain factors and the terms of the policy.

To ensure your claim is accepted and honoured, it is critical that you inform the insurer on time.

Prepare Your Claim Documents Carefully

Every document is essential for verifying your claim, so keep everything organised. Your health insurance claim can only be settled promptly if all documents required for the health insurance claim process are in order.

Make sure you have all the necessary paperwork in place, like the claim form, all medical bills, prescriptions, test reports, etc., handy. Missing or incorrect documents can delay your claim process or may lead to rejection.

Maintain Proper Communication

Every claim is unique, and there might be situations that do not fit neatly into standard processes. Effective communication with your insurer is key to resolving such issues.

Be prompt in providing the required details and answer the insurer's queries truthfully. This transparency helps create a smoother path toward claim settlement.

Insurance claims can sometimes feel overwhelming, but staying informed and following the right process makes all the difference.

Beware of the Co-Payment Clause

You can file an insurance claim only if the total amount incurred by you exceeds the co-payment sum. For example, the sum insured is ₹3,00,000, the co-payment amount is ₹30,000 and the expenses incurred are ₹1,00,000. In this situation, you can only file a claim for ₹70,000 (1,00000-50,000). On the other hand, if the co-payment is ₹1,00,000 and the expenses incurred are ₹75,000, you cannot raise a claim. Hence, it is crucial to know the co-payment clause details.

Also Read: Health Insurance Claim Process

Filing a health insurance claim can be straightforward if you follow the tips mentioned above carefully. However, making certain mistakes can lead to claim rejection or complications. Here are some common errors you should avoid when filing a health insurance claim:

Hiding Your Health Status

When purchasing health insurance, transparency is crucial. If you hide pre-existing conditions or provide incorrect information about your health, your claim may be denied. You can receive comprehensive coverage under your health policy, but only if all health details are accurately disclosed. Be honest during the application process to avoid unpleasant surprises later.

Delaying in Informing the Insurer

Informing the insurer about the medical emergency or incident within the specified time is one of the foremost requirements for admitting a claim. Thus, it is essential that you follow the timeline and inform the insurance company within the timeframe to avoid claim rejections.

Incomplete Documentation

Submitting wrong or incomplete documents is another mistake that you must avoid when filing an insurance claim. If you miss attaching essential documents, such as medical bills, diagnostic reports, doctor’s recommendation letter, etc., it can lead to a failed claim.

Not Understanding Your Policy

It is advisable to avoid making guesses about the policy coverage and terms. Failing to read or to understand the policy’s terms, inclusions and exclusions may cost you your insurance claim. Filing a claim for an incident or expense that is not explicitly covered under the policy may lead to claim rejection.

Failing to Renew Your Policy on Time

Health insurance policies typically require yearly renewal. If you miss your renewal date, your coverage will lapse, and any claims made during that period will be rejected. Hence, the best practice is to renew the policy before its expiration date. In any case, if you fail to renew the policy before its expiry, you may get a grace period, which you can take advantage of.

Delaying Claim Submission

Filing a claim late can be as problematic as not filing it at all. Whether it is a cashless or reimbursement claim, make sure you initiate the process within the specified timeframe mentioned in your policy. Prompt action ensures smoother processing and quicker settlements.

Claiming for Ineligible Hospital Stays

Unless your hospitalisation is part of a daycare procedure covered by the insurer, claims for hospital stays of less than 24 hours may be rejected. Always check your policy document to confirm whether your treatment qualifies. Avoid making claims for minor procedures that can be handled on an outpatient basis.

Not Taking Pre-Authorisation

Ignoring the need for a pre-authorisation from the insurer can be a reason for your claim rejection. If you fail to obtain pre-authorisation, especially in case of a planned cashless claim, the insurer will reject the claim on the spot.

Also Read: Claim Rejection and Claim Repudiation in Health Insurance

There are two common ways to file a health insurance claim: cashless claims and reimbursement claims.

Cashless Claim Process

As per the new rules of IRDAI, now you can get a cashless treatment facility even at a non-network hospital if you have an updated health insurance policy in place. So, instead of you settling the bill, the insurer will directly pay the hospital for the approved medical expenses.

To make a cashless claim, you need to:

• Intimate the insurance company about the hospitalisation - preferably 48 hours before planned treatments or within 24 hours for emergencies.

• Submit your health card and complete the necessary paperwork at the hospital.

• The insurance company will directly coordinate with the hospital and pay the bill after the treatment is completed.

This process ensures that you can focus on recovery without worrying about payments.

Reimbursement Claim Process

If you choose the reimbursement option, you will need to pay the medical bills upfront and then file a reimbursement claim with the insurer by following these simple steps:

• Submit the Reimbursement Claim Form: Complete the reimbursement claim form accurately and submit it along with the required documents.

• Wait for Claim Settlement: Once you submit the completed claim form and all necessary documents, the insurance company’s team will review and verify them. After successful verification, they will process your claim and reimburse the approved amount.

Also Read : Cashless Vs Reimbursement Claims

Deductibles and copayments play a big role in how your health insurance claim works. A deductible is the amount you need to pay from your pocket before the insurer starts covering your medical expenses. For example, if your deductible is ₹10,000, you will have to pay that amount first before your policy benefits kick in.

A copayment (or copay), on the other hand, is a fixed amount you pay for specific services like doctor visits or tests, even if the actual cost is higher. It is your share of the expense, while the insurer covers the rest.

Choosing a plan with lower deductibles and copays may lead to higher premiums but makes accessing healthcare more affordable when you need it. Understanding these costs helps you manage your health expenses better and ensures a smoother claim process.

A Health Insurance Ombudsman is a government-appointed authority that helps resolve disputes between policyholders and insurers. They act as neutral mediators to ensure fair treatment and quick resolution of issues.

What Does a Health Insurance Ombudsman Do

• Handling Complaints: Investigates issues like claim denials, delays and coverage disputes.

• Mediation: Bridges communication between you and your insurer to find solutions.

• Guidance: Explains your policy rights, terms and conditions.

• Ensuring Fair Practices: Promotes transparency and fair dealing by insurers.

• Recommendations: Offers solutions when disputes remain unresolved—insurers often follow these.

• Timely Resolutions: Aims for quick settlements, saving you time and hassle.

When to Approach an Ombudsman?

• Claim rejections or delays.

• Disputes over policy coverage or terms.

• Unfair treatment by the insurer.

• Poor or unresponsive communication.

How to Contact the Ombudsmen?

You can find the Ombudsman's contact details on the official IRDAI website. Complaints can be filed online or by submitting a physical form, as per the provided guidelines.

Filing a health insurance claim does not have to be stressful if you follow the right steps. Knowing your policy, keeping your documents ready and understanding the claim process can make a huge difference. At TATA AIG, we make it simpler for you with features like cashless claims, online claim filing process and 24*7 assistance.

Whether you are looking to buy health insurance for the first time or want to renew your existing health insurance policy, we are here for you. From policy purchase and renewal to premium payment, claim filing and tracking, we are with you every step of the way.

Plus, securing the best health insurance policy does not have to be expensive. With plans starting at just ₹17 per day, you can enjoy comprehensive coverage without breaking the bank.

So why wait? Buy health insurance online from TATA AIG today and experience a hassle-free claim process whenever you need it. Remember, with TATA AIG, it is “With You Always.”

*The rate is indicative and may vary based on the chosen health insurance policy, coverage, add-ons and other factors. Please read the policy details carefully and review the terms and conditions before making a purchase.

What if my health insurance policy expires before I make a claim?

If your health insurance policy lapses before you file a claim, it is considered inactive and your insurer will not process the claim. To avoid this, always renew your policy on time to maintain continuous coverage and hassle-free claims.

What do you mean by Network and Non-network Hospital, and does it make any difference in the claim process?

A network hospital has a tie-up with your health insurance provider, unlike a non-network hospital. While you can avail of cashless treatments at both network and non-network hospitals, the process is relatively quicker and smoother with network hospitals, since they are already empaneled with the insurer.

What is the maximum number of claims allowed during the policy period?

There are no such restrictions on how many claims you can make during the policy period. However, the total claim amount across all claims should not exceed the sum insured under your health insurance plan.