Filing Health Insurance Claim? - Here are a Few Details to Remember

Filing an insurance claim is never as easy as it seems

Buying health 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.
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.

There are several things you should understand while purchasing a health insurance plan, and the workings of a health insurance claim are one of the most critical amongst those. A health insurance claim is the claim you submit to your selected health insurance provider for the expenses related to your medical treatment, including hospitalisation. This claim may take one of the following forms:

1. Cashless claims submitted for the payment of medical expenses at the network hospitals of your insurer.
2. Reimbursement claims filed for the reimbursement of medical expenses incurred at a non-network hospital.

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 Tata AIG's Network Hospitals are available on Tata AIG 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 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 Toll Free Number 1800 266 7780.
• Senior Citizens can call our dedicated line at 1800 22 9966

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 7,200 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 claim settlement ratio of 94.21% for FY 2020-2021 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

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.

Being mindful of the various important things mentioned above can help you file a successful health insurance claim. At Tata AIG, we have a streamlined and customer-friendly health insurance claims process. You can file a health insurance claim at our website and seek the assistance of our 24x7 support team should you need it. Stay safe and healthy!