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.

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 a Claim Intimation/ Reference Number. Documents to be produced to avail the Cashless services are Listed Below.

1. Insurance Card
2. Policy Copy
3. Customer ID Proof with Photo
4. Customer Address Proof.
5. 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 Email ID.

In case the insurer does not provide a 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.

Address for Retail Customers: TAGIC Health Claims, TATA AIG General Insurance Company Limited, 5th and 6th Floor, Imperial Towers, H.No 7-1-6-617/A, GHMC No - 615,616, Ameerpet, Hyderabad – 500016, Telangana.

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 healthclaimsupport@tataaig.com
• Call our 24X7 Customer Support 022 6489 8282.
• Senior Citizens can call our dedicated line at 1800 267 1955

Here are some critical things you should make a note of while filing a health insurance claim.

1. The validity of your medical insurance plan

It is important to remember that you can only file a health insurance claim on a valid medical insurance plan. If your health insurance plan has expired and you have failed to renew it, any claims filed on the said plan will not be entertained by the concerned insurance company. Therefore, it is of critical importance to be mindful of the validity of your medical insurance plan and ensure its timely renewal.

Whether you have purchased an individual health insurance plan or medical insurance for your family, you must make a note of its tenure and expiration and set a reminder for its renewal so as to ensure that you are not left stranded without the benefits of health insurance when you are in need of them.

2. The inclusions and exclusions in your health insurance plan

The significance of perusing the inclusions and exclusions of your health insurance plan cannot be overstated. It is important to read the policy document in its entirety and make a note of the aforementioned particulars so as to have absolute clarity on the extent of the coverage you have. Secondly, this exercise helps you ensure that you select the most suitable health insurance plan for yourself and/or your family.
Remember that should you file a health insurance claim for an ailment or condition that is beyond the scope of your medical insurance plan, said claim shall be void ab initio. Therefore, you must ensure that you are aware of the inclusions and exclusions in your health insurance plan.

3. The coverage and waiting period for specific diseases and medical conditions

Whilst some illnesses are covered in a basic health insurance plan, some others are not. For instance, pre-existing diseases and critical illnesses may not be covered by all medical insurance plans. Even if there is coverage for these illnesses, there may be a specific waiting period before this coverage becomes activated and usable.
Therefore, if you have a pre-existing illness, you should purchase a health insurance plan that provides coverage for it. Secondly, you can add a cover for critical illnesses by buying the relevant medical insurance add-on. Following this simple process can help you ensure that while filing a health insurance claim, you can be assured of sufficient coverage in line with your health insurance requirements.

4. The health insurance claim process of your insurance provider

While purchasing a health insurance plan, you must go through your insurer's claim process for health insurance and keep the important elements in mind, including:

• The timeline for filing a claim for treatments at a network hospital and a non-network hospital.
• The various documents required to file a cashless claim and a reimbursement claim.

5. The cashless hospital network of your insurer

One of the most valued features of contemporary health insurance in India is the extensive hospital network of medical insurance providers. With this network, you can get access to cashless medical insurance and cashless claims and have a relatively worry-free claims experience.

At Tata AIG, we take our motto of 'With You Always' very seriously and are committed to providing you excellent health insurance support through our 12000 plus network of hospitals across the nation.

You can locate the network hospital nearest to you and get your medical treatment there, and we will take care of the bills. Our health insurance High claim settlement ratio bears testimony to our continued commitment to the provision of a seamless claims process to all our policyholders.

6. The documents required to file a claim

Whether you are filing a cashless claim or a reimbursement claim for health insurance, there are certain documents that you must keep handy in order to ensure that said claim is sufficiently supported and substantiated.

Here are some of the important documents required for filing a medical insurance claim:

• Your health insurance card;
• A copy of your health insurance plan;
• Your photo identification proof and proof of address;
• A copy of the First Information Report filed with the local police (applicable only for accidental claims);
• Duly filled CKYC form if the amount of the claim is in excess of ₹1 lakh.

If you have taken medical treatment at a non-network hospital, you will also need to submit some additional documents with your reimbursement claim, including:

• A Medical Certificate signed by a registered doctor;
• The original hospital and pharmacy bills;
• The applicable pathological test reports;
• A copy of your hospital discharge letter;
• Your NEFT details for the reimbursement.

If you do not receive a response from us within one month or are 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 to the 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.
• Self-declaration, if you hadn’t made any claims with your old insurer
• If you had made claims with your old insurer, the claim details are required

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.