Here's how your health insurance claim gets paid

You can get your claim either as reimbursement on producing valid proof of covered expenses or as a cashless service at a partner hospital.

Here's how your health insurance claim gets paid

Your health insurance plan is only as good as the financial support it provides when the time comes to make a claim. Being familiar with how the insurance claim process works will help you significantly while looking to compare health insurance plans and pick the one that best suits your needs.

Health insurance plans in India are primarily classified as either indemnity plans or defined benefit plans with respect to insurance claims. While an indemnity plan reimburses the cost of expenses incurred on account of an illness or hospitalisation, a defined benefit plan offers a lump sum payout on the detection of a disease covered under the terms and conditions of the insurance policy.

Let’s understand when claims can be made on health insurance plans and how the settlement happens.

Filing the insurance claim

Before anything else, it is recommended that you go through the policy document carefully to understand all the terms and conditions. With the exception of some daycare procedures such as cataract surgery, tonsillectomy, chemotherapy, dialysis, etc. which will be explicitly mentioned in the policy document. Most health insurance plans require the policyholder to be hospitalised for a minimum of 24 hours to avail of insurance benefits. 

There will be a waiting period for certain illnesses, exclusions for others, and certain procedures may have only limited coverage. You need to be aware of the coverage and caveats so you are not caught off-guard while making a claim. The best health insurance plans are the ones that impose minimum restrictions.

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Getting the claim reimbursed

Most of the best health insurance plans in India are based on an indemnity cover, also known as a mediclaim policy. The claim fulfilment of an indemnity plan can happen in two ways – either as reimbursement on producing valid proof of covered expenses or as a cashless service at a network hospital. 

While claiming reimbursement, you will have to submit all relevant bills associated with the medical treatment cost. The insurer will then assess the bills and reimburse you based on the limit of your sum assured. The process can take 15–30 days depending on the insurer. If the claim is delayed beyond 30 days, the insurance company becomes liable to pay interest on the delay as per IRDAI guidelines.

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A cashless facility, on the other hand, gives you all the healthcare benefits without requiring you to pay anything out of your pocket, as long as you are availing the service from a hospital that is part of your health insurance company's network. When you compare health insurance plans, ensure that the insurance provider has a hospital in its network that is close to your home and place of work.

To avail of a cashless claim, all you need to do is fill out a pre-approval form at the hospital desk, and submit a proof of identity and your health card. The third-party administrator (TPA) at the partnering hospital will take care of the rest. If you want to know about co-pay and deductibles in detail, read here


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