Health Insurance Claims Processing

In a cashless claim, the policyholder is not expected to pay the hospital bills as the insurer reimburses the same. If treatment was availed through network hospitals listed with your insurer, you generally don’t have to pay anything to the hospital. Your insurer or their third party agents (TPA) will take care of your bill and settle it with the hospital directly. Request for cashless claim needs to be placed by submitting a hardcopy or through customer care. Request can even be placed online, which is more convenient.

In a reimbursement claim, the policyholder has to pay the hospital bills and then it is reimbursed by the insurer. The reimbursement claim for health insurance can be made if the policyholder opts to go to a hospital of his/ her choice, which is a non-empanelled hospital. In this case, the cashless claim facility cannot be used. Therefore, the insured has to pay all his/ her medical bills and other costs involved in hospitalization and treatment and then claim reimbursement. In order to avail reimbursement, claim you have to provide the necessary documents including original bills to the insurance provider. The company will then evaluate the claim to see its scope under the policy cover and then makes a payment to the insured.

In case of a cashless claim, follow the steps given below:

Step 1:

Check whether the illness is covered in your policy. Also, check if the hospital is a network hospital.

Step 2:

Inform your insurer about the hospitalization within 24 hours. You will be asked to fill a Pre-Authorization Form and submit it at the TPA (Third Party Administration) counter at the hospital. They will then forward the form to the insurer for approval.

Step 3:

You will be required to submit documents like Cashless Health Card provided by the insurer and other KYC documents for identification.

Step 4:

Once insurer approves your claim, the original documents pertaining to hospitalization will be retained by them. For your records, you must keep a copy of these documents.

Step 5:

Retain the pre and post hospitalization bills and associated prescriptions/medical reports to claim them later. It is advisable to check the coverage of these expenses in your Policy Document.

In case of reimbursement (i.e. when you don’t opt for a cashless facility or when the hospital is not covered in the cashless network), following are the steps followed:

Step 1:

Inform the insurer. Fill and submit the reimbursement claim form within 30 days from the date of discharge. This form is available with the insurer.

Step 2:

Get the original copies of medical reports, medicine bills and hospitalization bills stamped and signed and submit them along with the claim form.

Step 3:

Submit the Discharge Summary/Card to the insurer.

Step 4:

Submit your doctor’s follow-up prescription in original to the insurer. Submit post hospitalization expenses bill within 30 or 60 days from discharge as per the terms of your policy.

Step 5:

Retain copies of all the submitted documents for future reference and wait for the settlement of your insurance claim. (Generally, the claim will be settled in 2-3 weeks)

HDFC Life offers various health insurance plans and with an extremely impressive claim settlement ratio, we seek to protect your finances from any risks due to health related contingencies. For details, click on the mentioned link: https://www.hdfclife.com/health-insurance-plans