A step-by-step process to make health insurance claim

A health insurance claim is a request to your insurer for medical expense coverage, either cashless or reimbursement. Inform your insurer as required and keep documents like the claim form, discharge summary, prescriptions, and bills ready for submission.
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3 mins
30 July 2023

Health insurance policies act as a financial safety net during unexpected medical emergencies, helping you manage costly treatments without stress. To make the most of your health insurance coverage, it’s essential to understand how the claim process works. There are two primary ways to settle a health insurance claim: cashless claim settlement and reimbursement claim settlement.

In this article, we’ll walk you through both types of claim processes, the documents you’ll need to submit, and useful tips to help you avoid claim rejections.

How to make a health insurance claim?

The first thing to do when making a health insurance claim is to inform the insurance company as soon as possible. It is important to adhere to the time limit specified in the policy for filing a claim. The insurer’s representatives guide you through the claim process on documents you need to submit and how to fill out the claim form. If you do not inform the insurer in time, your health insurance claim may get rejected. For more details on how to claim medical insurance, refer to the policy guidelines and insurer's instructions.

How to file a health insurance claim?

  • Step 1: Inform your insurer immediately—either before hospitalization (for planned treatment) or within 24 hours (for emergencies).
  • Step 2: Choose between cashless or reimbursement claim.
  • Step 3: Submit required documents like claim form, bills, discharge summary, etc.
  • Step 4: Wait for claim verification and approval from the insurer.
  • Step 5: Receive settlement—directly at hospital (cashless) or in your bank account (reimbursement).

Pro Tip

A comprehensive health plan not only covers hospitalization but also pre & post-treatment expenses, ensuring complete financial protection against rising medical costs.

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What are the claim process of health insurance?

The health insurance claim process includes cashless and reimbursement options, each with distinct steps and documentation requirements.

Cashless health insurance claim settlement process

  • Get admitted to a network hospital for planned or emergency treatment.
  • Show your health insurance e-card at the TPA desk.
  • Fill and submit the pre-authorisation form.
  • Insurer reviews and approves the claim directly with the hospital.
  • No out-of-pocket payment needed, except for exclusions or non-covered costs.

This process allows you to receive treatment without paying upfront, easing financial stress during emergencies.

Reimbursement health insurance claim settlement process

  • Get treated at any hospital, whether in-network or not.
  • Pay all medical expenses out-of-pocket initially.
  • Collect all bills, reports, and discharge summary.
  • Submit a claim form and supporting documents to the insurer.
  • Insurer verifies and reimburses the eligible amount to your bank account.

This process offers flexibility to choose any hospital and claim the expenses post-treatment.

Types of health insurance claims

Here are the two ways that you can file a health insurance claim.

Cashless claim settlement

In a cashless health insurance claim, the insurer directly deals with the network hospital. Here you only need to get treated or admitted at any of the nearest network hospitals and inform the insurer. You need to give a claim intimation within 48 hours of emergency admission or 72 hours before planned hospitalisation. Also, contact the insurance desk at the hospital immediately after getting admitted. Following which the admin will send a pre-authorisation form, claim form, and necessary documents to the insurer.

If you already got the pre-authorisation form approved by the insurer, the process will start sooner. Upon reviewing the documents, insurer will approve the claim if it is within the policy terms and conditions and settle the bills directly with the network hospital.

Reimbursement claim settlement

This facility enables you to choose any of your preferred hospitals to get the treatment. The only difference here is that you will need to clear the hospital bills first and then claim for reimbursement. You need to give a claim intimation to the insurer within 48 hours of emergency or three days before planned hospitalisation for the reimbursement claim process.

For effective management of health insurance claims, after getting discharged, submit the hospital bills, discharge summary, doctor’s prescriptions, and reports to the insurer. You may need to submit a few documents as required or asked by the insurer. After reviewing the documents and verifying the claim’s authenticity, the insurer will reimburse the claim amount within 10-15 working days. In some cases, it may take up to 30 days. This depends on the insurer and their policy terms and conditions. You will receive the claim amount in your registered bank account.

Types of hospitalisations covered by health insurance claims

Health insurance policies typically cover various types of hospitalisations, enabling you to make a medical insurance claim for different medical needs. Here are the main types:

  • Emergency hospitalisation: Immediate treatment required due to sudden illnesses or accidents.
  • Planned hospitalisation: Scheduled treatments or surgeries for known medical conditions.
  • Daycare procedures: Treatments that do not require an overnight stay, such as cataract surgery.
  • Pre- and post-hospitalisation expenses: Costs incurred before and after hospitalisation for diagnostics and follow-up treatments.

Also, check the claim settlement ratio in health insurance.

What documents do I need to file a health insurance claim?

You mainly need to submit the documents if filing for a reimbursement claim. In case of cashless claim settlement, the network hospital takes care of everything.

Here is a list of documents that you need to submit when making a health insurance claim.

Filled claim form (both A and B)

You can download the claim form from the insurer’s website. You will also get it at the hospital’s insurance desk.

Medical bills and reports

You will need to provide all original medical bills and reports from the hospital.

Discharge summary

This document has the details of the treatment taken and the diagnosis given.

Prescription and medical certificate

A prescription from the treating doctor and a medical certificate confirming the need for hospitalisation.

Identity proof

You need to share valid identity proof like Aadhaar Card, passport, voter ID, etc.

Types of hospitalisations covered by health insurance claims

Health insurance policies typically cover various types of hospitalisations, enabling you to make a medical insurance claim for different medical needs. Here are the main types:

  • Emergency hospitalisation: Immediate treatment required due to sudden illnesses or accidents.
  • Planned hospitalisation: Scheduled treatments or surgeries for known medical conditions.
  • Daycare procedures: Treatments that do not require an overnight stay, such as cataract surgery.
  • Pre- and post-hospitalisation expenses: Costs incurred before and after hospitalisation for diagnostics and follow-up treatments.

Things to consider while applying for a health insurance claim

Here’s what you need to consider when applying for a health insurance claim. The following points will help you speed up the claim process and get your claim settled easily.

Make the claim in time

You need to inform the insurer about the claim within the specified time in your policy. Avoid any delays. For reimbursement, you need to submit the documents to the insurer within 15 days of getting discharged.

Accuracy of information

Ensure you provide all the information in the claim form accurately. Also, share the correct documents with the insurer. Any incorrect information can lead to the rejection of the claim.

Adequate coverage

Make sure that you have adequate coverage under your health insurance policy to meet the medical costs incurred.

Avail of cashless facility

If the hospital has a tie-up with your health insurance company, opt for a cashless facility. The hospital will then take care of the claim settlement directly with the insurance company.

How to manage health insurance claims from multiple insurance providers?

If you have health insurance policies from multiple insurance companies, you can raise a cashless claim with any one insurer for all medical expenses. Once the first insurer settles your claim, contact the second insurer to cover the remaining medical expenses.

Submit the claim settlement summary from the first insurer along with the attested hospital bills and payment receipts to the second insurance company. The second insurer will review your claim against their policy terms and conditions and then pay you the claim amount accordingly.

Tips to avoid health insurance claim rejections

Here are some tips that you must consider to ensure your health insurance claim gets accepted easily.

Keep the policy up to date

Make sure to pay the health insurance policy premiums on time to ensure that the policy remains in effect. Also, see that your policy has not expired.

Disclose all medical information

Ensure that you disclose all your medical history, pre-existing conditions, etc. in the health insurance proposal form.

Adhere to terms and conditions

Read the policy terms and conditions carefully. It mentions the time limit for filing a claim, the deductible amount you may have to pay, etc. Also, conditions for making a health insurance claim for a specific illness, if any.

Seek pre-authorisation

Before undergoing any treatment, seek pre-authorisation from the insurance company. This will ensure that the claim does not get rejected later.

Steps to check the status of a health insurance claim

You can check the status of a health insurance claim in the following ways:

Check health insurance claim status online

Most insurance companies allow you to check the status of your claim online through their website or mobile app. You need to enter your policy number or claim reference number to check the status. For more detailed guidance on how to claim health insurance online, refer to the insurer's official website or app.

Call the insurer

You can call the insurer’s customer care helpline and provide your policy number or reference number to check the status of your claim.

Visit the insurance branch office

To check the health insurance claim status offline, you can also visit the insurance company’s branch office.

Making a health insurance claim can seem like a daunting task, but with the above information, you can ensure a smooth process. The health insurance claim process varies depending on the type of claim filed, and the documents required. You should ask your insurance company about the claim process in detail when buying the health insurance policy. It will help you make health insurance claims easily.

Conclusion

Filing a health insurance claim may seem overwhelming, but with the right information, it becomes a manageable task. The process can differ based on whether you opt for a cashless or reimbursement claim, and each requires specific documentation. Always clarify the claim process with your insurer at the time of purchase to avoid confusion later and ensure hassle-free claim settlements.

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Frequently asked questions

When can I make a health insurance claim?

You can make a health insurance claim when you get hospitalised for medical treatment. You can make the claim in two types, either opt for a cashless claim or a reimbursement claim. For a cashless claim, you need to seek treatment at a network hospital. For reimbursement claims, you can choose any of your preferred hospitals.

Can I make a yearly claim for health insurance?

Yes, most health insurance policies allow policyholders to make a yearly claim. However, the limit for a claim amount may differ depending on the policy. Typically, policyholders can claim up to a limit each year, and the insurer will not payout anything above that limit.

What percentage of medical coverage can I claim?

The percentage of medical coverage that you can claim depends on the policy's terms and conditions. Most policies cover medical expenses ranging from 70% to 100% of the total expenses incurred. You will find the total limits for claims defined explicitly in the policy agreement.

When does a claim get rejected?

Claims can get rejected for various reasons: non-disclosure of pre-existing medical conditions, delay in filing the claim, or unapproved treatment providers. Some other reasons include medical procedures taken outside of the policy's specified coverage and policyholders under/over-insured. Providing inaccurate or incomplete information while filing the claim can also lead to claim rejection. It is important to adhere to the policy terms and conditions and provide all relevant information when making a claim to avoid rejection.

How much can we claim for health insurance?

There is no pre-defined amount that can be claimed for health insurance. This generally varies based on the type of plan, coverage and insurance premium.

How do I claim a health insurance settlement?

To claim a health insurance settlement, notify your insurer, submit required documents like hospital bills, discharge summary, and claim form. For cashless claims, use the network hospitals. For reimbursement, pay the bills first and then submit the documents for reimbursement.

What are the Top Reasons for Rejection of Health Insurance Claims
  • Incomplete or incorrect documentation during the claim submission process
  • Non-disclosure of pre-existing conditions at the time of buying the policy
  • Claiming for exclusions not covered under your health plan
  • Missing deadlines for intimation or submission of documents
  • Treatment at non-network hospitals for cashless claims
Role of Network Hospitals in Health Insurance Claims
  • Network hospitals enable cashless claim settlement, reducing upfront medical expenses
  • Insurers settle bills directly with these hospitals, simplifying how to claim medical insurance
  • Pre-authorization is faster and smoother at empanelled hospitals
  • It helps avoid reimbursement delays and out-of-pocket hassles
  • Ensures better coordination between hospital and insurer during emergencies
How many days after we can claim health insurance?


The timeframe to file a health insurance claim depends on the insurer and the type of claim. For reimbursement claims, most insurers allow you to file within 7 to 30 days from the date of discharge. However, for cashless claims, the insurer should be informed within 24 hours of emergency hospitalization or at least 48–72 hours before a planned admission.

Can we claim health insurance immediately?

Health insurance claims can be made immediately in case of emergencies, but some policies come with a waiting period for specific illnesses or treatments. For accidental hospitalization, coverage usually begins from day one. However, for illnesses, a waiting period of 30 days from the policy start date typically applies before you can make a claim.

Can I claim insurance after 1 day?

Yes, you can claim health insurance after 1 day, especially in the case of emergencies or accidents. For reimbursement claims, ensure that you collect all valid documents and inform the insurer within the required time. The claim will be processed as long as it falls within policy terms and isn’t within the waiting period for specific treatments.

How to claim a hospital bill?

To claim a hospital bill, inform your insurer or TPA immediately after hospitalization. For reimbursement, pay the hospital bills upfront and collect all original documents including bills, reports, and discharge summary. Submit these with a filled claim form to your insurer. For cashless claims, submit a pre-authorization form at the network hospital and let the insurer handle direct payment.

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