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How to File a Claim for Health Insurance and Mediclaim and the Claim Settlement Process

Posted On : 17 July 2023, 9 Months Ago. Blog Total Read 1476

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People who are blessed with a healthy life hardly understand the value it holds. Healthy life provides you with an opportunity to succeed every day. But with a degraded environment and immense work pressure, people have started living an unhealthy life. This lifestyle has negative consequences for long-term health, resulting in various health issues. In order to safeguard your finances, it is beneficial to get yourself and your loved ones secured under health insurance plans. This blog will guide you through healthcare insurance and the process of settling a health insurance claim.

What is Healthcare Insurance?

Healthcare insurance is a policy document that provides medical coverage against unfortunate events like hospitalisation, daycare procedures, post-hospitalisation expenses, etc. One can avail the benefits of medical insurance by paying an annual premium against the coverage provided. The premium varies with insurance plans, insurer, and medical condition of an individual. It also involves add-on covers such as critical illness, personal accident cover, maternity cover, etc. There are various plans available according to the need of the individual. Here are some common plans:

Family Floater Plan: This type of medical insuranceprovides coverage to the whole family rather than just a single person. Every member of the family can avail the benefits offered by investing in just one plan.
Group Health Policies: As the name suggests, Group Health insurance plans cover a group of people who work under the same organisation. This is a benefit offered by the employer to its employees as the premium is borne by the employer.
Senior Citizens Health Plans: People who are above 60 years of age are eligible to buy Senior Citizen Health plans. It provides coverage for the cost of hospitalisation, medicines, domiciliary hospitalisation, psychiatric benefits, etc.
Individual Healthcare Insurance: This type of medical insurance provides coverage to a single individual. The insured person can avail cashless medical treatment in the network hospitals. The premium for the plan depends on the buyer’s age and medical history.

How to File a Claim for Healthcare Insurance and Mediclaim?

One of the most vital factors of healthcare insurance is the process involved in health insurance claim settlement. To get the required benefits, one has to either opt for a cashless claim or reimbursement. Both processes are explained below:

Cashless Claim

An insured can seek cashless treatment from network hospitals under the insurance policy. During the time of admission, the individual must produce a cashless health card issued by the insurer, as the medical expenses will be directly settled by the insurer. There are two ways to claim cashless treatment, which are mentioned below:

Process for Planned Admission

Here is step by step guide to avail of cashless claim in case of planned admission:

Select a hospital among the network hospitals to avail of the medical services.
nform the third-party administrator (TPA) 3 days before admission and provide a membership number along with this.
Fill out the cashless treatment request form at the hospital.
Submit the form and medical reports to TPA, after which the TPA will inspect all the documents.
Once approved, the insurer will settle the medical bills.
In case of disapproval, the individual can file for reimbursement of the same.

Process for Emergency Admission

Mentioned below is the process of filing a claim in case of emergency admission:

Provide information to the TPA along with the membership number.
Fill out a cashless process form at the hospital.
Send the form with the attached medical reports to TPA.
Once approved, medical bills will be settled by the insurer.
In case of disapproval, file for reimbursement.

Reimbursement

In case of reimbursement, an individual has to initially pay the medical bills and then file a claim for reimbursement. A person must submit all the medical bills at the time of filing a claim. After verification, the insurer pays the amount directly to the bank account of the policyholder. When the insurer wants to avail treatment from a non-network hospital, reimbursement is the process they need to follow. Here are the steps involved in filing the claim:

Provide a membership number to the insurance company.
Settle all the hospital bills.
Present all the required documents, like bills, discharge summary, prescription, etc., when you request claim settlement.
Fill out the reimbursement form from the company’s website.
Submit the form along with medical records to the insurer.
One can expect the reimbursed amount through a check after approval.

The process generally takes around 20 days from the date of receipt of all documents.

It is advisable to keep your documents updated if you are planning to get reimbursement or avail cashless treatment. Unless all the necessary documents are available, one can not get the claim settled. Moreover, one should consider a good and reputed insurance provider so that they can experience a hassle-free claim settlement process.

The above-mentioned settlement criteria will help you understand and initiate a health insurance claim.

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Secure your health with comprehensive insurance plans from Nivabupa

Tell us a bit about you

Whom are you buying for ?

Individual

Husband & Wife

Family

Name Enter valid name

Date of Birth Enter Valid DOB

Mobile Number

OTP sent Resend OTP

OTP

OTP Expires in

I authorize Niva Bupa to call me. This will override your existing registry in DNCR. I want to get my quote and policy details on WhatsApp.

FIND MY PLAN

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