When you need to make a claim on your health insurance policy, it’s important to follow the proper procedure to ensure that your claim is processed smoothly and efficiently. Below is a detailed guide outlining the steps for both cashless and reimbursement claims, whether you’re in India or outside the country.

• Notification of Claim

Notification of a claim is the initial step where you inform your insurer about your hospitalization or treatment. This prompt communication is essential for a smooth claims process.

a) When to Notify:

• Emergency hospitalisation: Within 24 hours of admission or occurrence of the emergency
• Planned hospitalization: At least 48 hours prior to admission in a hospital or decision to avail treatment.

b) How to Notify:

As soon as you are admitted or receive treatment, contact your insurer’s claims department. Many insurers provide a dedicated helpline, email address, or mobile app for this purpose.

c) Information to Provide:

• Your Policy Number
• Name(s) of the Insured Person(s)
• Date and time of admission or treatment
• Name and address of the hospital or treatment center
• Brief details about the illness or injury

Timely notification ensures that the claim process begins without unnecessary delays.

• Procedure for Cashless Claims

If you choose to receive treatment at a network hospital, you can avail of the cashless facility. The process is as follows:

a) Pre-Authorization Process:

• Initiation: The Network Provider (hospital) will obtain the necessary information from you or the policyholder and submit a Cashless Facility request using the cashless request form available with them.
• Verification: Upon receiving the request form and related medical information, the insurer reviews your policy details and issues a pre-authorization letter to the Network Provider after verification.

b) At Discharge:

• You must verify and sign the discharge papers along with the final bill.
• You are responsible for paying any non-medical or inadmissible expenses.

c) Denial of Cashless Access: If you are unable to provide the required medical details or if pre-authorization is denied, you may still obtain treatment as advised by your doctor and later submit the claim documents for reimbursement.

• Procedure for Reimbursement Claims

If you receive treatment at a non-network hospital or opt not to use the cashless facility, follow these steps:

a) Payment: Settle the hospital bill at the time of discharge.

b) Submission Time Frames:

• Hospitalization, Day Care Treatment, or Pre-Hospitalization Expenses: Submit your claim within 30 days of the date of discharge.
• Post-Hospitalization Expenses: Submit your claim within 15 days from the completion of post-hospitalization treatment.

c) Filing the Claim: Complete the insurer’s claim form accurately and attach all required documents. Submit the complete package within the prescribed time limits.

• List of Documents Required for a Reimbursement Claim

Ensure your claim is supported by the following documents:

a) Duly Completed Claim Form

b) Photo ID and Age Proof

c) Hospital Registration Details: A copy of the Hospital’s Registration Certificate or Registration Number if the hospitalization is in a non-Network Provider, or a certificate from hospital authorities listing available facilities (e.g., number of beds)

d) Discharge Documents: Discharge Card, Day Care Summary, or Transfer Summary

e) Final Hospital Bill: All original deposit and final payment receipts, including refund receipts if an advance was refunded

f) Consultation Papers: Previous consultation records indicating your medical history, treatment details for the current illness, and advice for the current hospitalization

g) Diagnostic Reports: All diagnostic reports (imaging and laboratory) along with the medical practitioner’s prescription and the invoice/bill with receipt from the diagnostic center

h) Medicine/Pharmacy Bills: All pharmacy bills along with prescriptions

i) Any Other Relevant Document: As required by the insurer for assessment of the claim

By adhering to the above procedures and ensuring timely notification and comprehensive documentation, you can help expedite the processing of your claim and secure reimbursement for your medical expenses efficiently.

Note: The information provided herein is for general informational purposes only and is intended to serve as an illustrative guide. Specific document requirements, notification time frames, and procedural details may vary significantly between different insurers and policies. This summary is not intended to be comprehensive or a substitute for the actual policy wording. For precise and up-to-date information, please refer to your insurer’s official policy documents or contact them directly.