Health Insurance Claim Settlement Process

Health Insurance Claim Process

Generally in India, there are three categories of Health Insurance Claims in most of the policies.

  1. Cashless Claim
  2. Reimbursement Claim
  3. Preventive Health Check-up claim.

Cashless claim :

is considered if the policyholder is admitted in Network hospital of that particular Company from which the policy is purchased. Each and every Health Insurance Company is having a list of Hospitals and Nursing Homes that comes under their Network. In these network hospitals there is a facility of cashless claim settlement for their policy holders. It means no treatment cost has to be paid by policyholder. All bills related to that particular illness treated in the hospital are paid by the Insurance Company directly to the Hospital. Hence, there is no burden on the policyholder for hospital bill payment.

Reimbursement Claim : 

is considered if the policyholder is being treated in non-network hospital of that particular Company from which the policy was purchased. In such case, all the hospital expenses are paid by the policyholder at the time of discharge from the hospital. All the bills related to that particular illness, duly signed claim form of the Insurance Company that has to be stamped and signed by the treating Doctor/ hospital and the policyholder as well, valid I’d proof of policyholder and bank details of policyholder are submitted in the Insurance Company for claim reimbursement. It normally takes 5-15 days for reimbursement depending upon the Insurance Company regulations. The pre and post hospitalization bills of the considered illness are also reimbursed by providing the valid medicine bills, diagnostic bills and Doctor Consultation bills regarding the treated illness/surgery.

Preventive Health Check-up Claim :

is considered as cashless and reimbursement both depending upon the Insurance Company. If the Insurance Company is providing cashless facility every year at prescribed Diagnostic centres then one can avail free health check-up every year or as available in the policy terms. Some companies provide preventive health check-up facility that is considered for reimbursement for certain limit of amount depending upon the basic sum insured of the policy. Higher the sum insured high amount for health check-up, lower the sum insured low amount available.

Why the Health Insurance claim is denied or rejected?

We have to understand that when a policy is sold to the customer, there are certain waiting periods for claims in the policy. These waiting periods are generally in all the companies operating in India. These are as follows:

  1. 30 days initial waiting period

  2. 1year/2 years waiting period

  3. 3 years/4 years waiting period

30 days waiting period means, No claim will be payable in first 30 days of fresh policy purchased except the claim arises due to any accident.

1 year/2 years waiting period means that there are some specific diseases/illness for which the claim will not be paid for first two years and in few companies for first one year. For example, the claims for Stone, piles, hernia, cataract, gynaecological problems, arthritis, ENT related issues, etc.  are not payable if they occur in first two years. These types of claims are considered for reimbursement or as cashless third year onwards from the inception date of the policy.

3 years/4 years waiting period means that if the person is suffering with some pre-existing disease at the time of purchase of policy then there will be a waiting period for that pre-existing disease related claim for three years or four years depending upon the Insurance company clause. No claim shall be payable for first 3 or 4 years from the date of inception of the policy related to that pre-existing disease/illness/surgery. For example, if someone is having hypertension and is on regular medication before buying the policy, then it should be declared at the time of purchase and a waiting period shall be applied on claims related directly or indirectly to hypertension.

If the pre-existing disease/illness/surgery is not disclosed at the time of purchase of the policy then each and every claim will be denied due to non-disclosure of material facts at the time of purchase even if the claim is related or non-related to that particular pre-existing disease/illness/surgery.

Denial of claims is also applicable on claims raised due to alcohol, smoking, drugs, HIV and by breaking any traffic bylaws.

In maximum Claims rejection, mostly there is one of the above reasons for denial by the Insurance Companies. So, one should buy health Insurance policy after disclosing all his previous medical history and pre-existing disease/illness/surgery. If each and every fact is explained and clear to the policyholder there shall be no chance of denial of claim.

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