Types Of Health Insurance Claims: Cashless Vs. Reimbursement

Health insurance serves as a financial safety net for individuals, mitigating the burden of medical expenses during unforeseen health issues. The process of seeking benefits and services covered by an online health insurance policy is termed a health or medical insurance claim. There are two primary categories: reimbursement claims and cashless claims.

Categories Of Health Insurance Claims

Cashless Claims:

In this type, the insurer pays the network hospital for medical costs, as the policy permits.

Cashless claims can only be availed in network hospitals.

Cashless Claims In Non-Network Hospitals:

The hospital must submit a cashless request to your insurance provider to initiate.

Pre-authorisation requests must be sent 48 hours before scheduled admission or emergency hospitalisation.

Reimbursement:

Policyholders pay the network hospital bills and later claim reimbursement from the insurance provider.

The insurer reimburses hospitalisation costs according to the policy’s terms and conditions.

Cashless Process For Scheduled Hospital Admission:

• Select a network hospital from the network list mentioned in the policy document.
• Visit the network hospital’s insurance help desk 72 to 48 hours before admission, presenting the policy card.
• Complete the required forms, including the pre-authorisation form.
• Your insurance provider pays network hospital bills up to the authorised amount upon approval; if denied, settle bills and request reimbursement.

Cashless Process For Urgent Hospital Admission:

• Present policy card to the network hospital’s insurance help desk.
• Complete the pre-authorisation form for a cashless claim.
• Your insurance provider settles the claim with the network hospital after deductibles or claims reimbursement is

Procedure For Reimbursement Health Insurance Claim:

• Inform your insurance provider about network hospital details and medical care received.
• Receive treatment at the chosen network hospital.
• Settle all network hospital expenses.
• Collect original hospitalisation records, including prescriptions, receipts, diagnostic reports, etc.
• Download and complete the health insurance claim form.
• Apply online or send a letter to your insurance provider for reimbursement.
• Submit the claim form and all relevant documentation.
• Your insurance provider processes the claim per policy terms; denial notifications are communicated.

Documents Required For Filing A Claim:

• Completed health insurance claim form.
• Patient’s discharge summary.
• Invoices for cash and medications.
• Reports on laboratory, X-ray, scan, and ECG diagnostics.
• First Information Report (FIR) or Medico-Legal Certificate (MLC) in case of an accident.
• Duplicate of the insurance policy.
• Original network hospital invoices and payment receipts.
• Cancelled cheque for reimbursement claims.
• Filing a Health Insurance Claim:
• Acknowledge premium payment to the insurer for financial security against medical costs.

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Tailored health insurance plans for parents are essential, offering comprehensive coverage for age-related health issues. These plans provide financial security, covering pre-existing conditions and ensuring parents receive quality medical care without undue financial strain. Claims are subject to terms and conditions set forth under the health insurance policy. *

Understanding the nuances of health insurance claims is essential for policyholders. Whether opting for cashless facilities or reimbursement, adherence to the insurer’s guidelines and timely submission of required documents ensures a smooth and efficient claims process, offering the intended financial security during challenging health situations.

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Disclaimer: The content on this page is generic and shared only for informational and explanatory purposes. It is based on several secondary sources on the internet and is subject to changes. Please consult an expert before making any related decisions.

Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.