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Health Insurance Claim

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Health Insurance Claim

Health insurance is designed to mitigate your medical care costs and provide you with a cushion if your health fails. There could be different situations when you may have to make a claim against your policy. This could be due to a planned or unplanned hospitalisation.

There are two ways you can raise a claim against your policy: Cashless or Reimbursement Claims. But, the procedures for these two types of health insurance claims are different, and it is vital that you understand their guidelines for a hassle-free experience. 

Medical insurance claim

A health or medical insurance claim is a process of requesting the insurer (in this case, ACKO) to provide the benefits and services covered in your health insurance policy. You can either opt for a cashless claim (also known as direct claim settlement) or a reimbursement claim for medical expenses incurred.

Types of health insurance claims

There are primarily two types of health insurance claims. These are as follows.

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Cashless claims

Under this type of health insurance claim, the insurer (ACKO) settles all the medical expenses (as covered by the policy) with the hospital directly. However, to avail of the cashless mode of claim settlement, the policy’s beneficiaries need to be hospitalised at a network hospital.

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Reimbursement claims

Under this type of health insurance claim, you pay the hospitalisation bill first and then file for the reimbursement of the hospitalisation expenses. The insurer (ACKO) will pay the amount to you as per the terms and conditions of the policy.

Cashless procedure for planned hospitalisation

Here are the steps for the cashless claim process in case of a planned hospitalisation.

If a cashless claim is not sanctioned, you can pay the bills and file for reimbursement of the medical expenses.

Cashless procedure for emergency hospitalisation

Here are the steps for the cashless claim process in case of emergency admission.

If the cashless claim is not approved, you can file for reimbursement.

Reimbursement procedure for a health insurance claim

Here is the process for reimbursement of the hospitalisation bills.

Note: In both types of claims, you must inform ACKO before or while seeking hospitalisation.

What are the documents required to make a claim?

Here is the list of common documents required while making a claim against your health insurance policy. However, documents may differ depending on the case.

  1. Duly filled health insurance claim form.

  2. Discharge summary of the patient

  3. Cash invoice

  4. Prescriptions

  5. Diagnostic reports (ECG/X-Ray/Scans/Laboratory)

  6. First Information Report (FIR) or Medico-legal Certificate (MLC) in case of an accident

  7. Copy of the insurance policy

  8. Original medical bills

  9. Original payment receipts

  10. Canceled cheque in case of reimbursement claims

How does the health insurance claim process work?

You pay a premium to your insurer (eg: ACKO), in return for financial protection in case of any unforeseen medical expenses. A health insurance claim is the process of informing ACKO about the medical expense, so they can compensate you as per the policy terms and conditions. The insurer is liable to pay your hospitalisation bills as per the terms and conditions mentioned in the policy.

You can raise a claim against your health insurance policy through the cashless or reimbursement procedure. When you opt for a cashless claim, the Third-party Administrator’s (TPA) role is to coordinate with all stakeholders to settle your claim as per the terms and conditions of the policy. However, in the reimbursement procedure, you need to register the claim directly with ACKO by submitting the claim online or by writing to us at [email protected]

Step-by-step procedure for filing a health insurance claim

For the reimbursement of the hospitalisation bills, you can raise your claim against your policy through our online platform or by writing to us. For more details, you can refer to our article on the step-by-step guide for raising a health insurance claim.

How to check the status of a health insurance claim?

As previously mentioned, there are two types of claims in health insurance, Cashless and Reimbursement Claims.

For cashless claims, you can check the status of your claim by approaching the insurance help desk of the hospital. They will initiate, process, provide details of deductibles and settle the claim by coordinating with ACKO.

On the other hand, for reimbursement claims, you can check your health insurance claim status by writing to us at [email protected]

How to claim health insurance from multiple insurers

It is ideal for securing yourself and your family with adequate health insurance to mitigate the rising medical expenses. You may have employer health insurance (mediclaim insurance/corporate health insurance) and a personal health insurance policy, or you may have taken two different private health insurance policies. You may be wondering if you can raise a claim from multiple insurance companies. The answer is yes.

All you need to do is make a claim with the first insurer against the medical care expenses. Then, you need to procure the summary of the claim settlement from the first insurer, get the hospital bills and receipts attested by the hospital, and approach the second insurer to settle the balance of your medical expenses.

Also, read: How to claim medical insurance from multiple insurers

What is a ‘Claim Settlement Ratio’ in health insurance?

You must secure yourself and your family with a health insurance policy that offers an adequate sum insured amount to mitigate rising healthcare costs and unforeseen hospitalisation expenses. However, it is also essential to select a dependable insurer. To help you find the right insurer, two ratios that can help you is - Claim Settlement Ratio (CSR) and the Incurred Claim Ratio (ICR).

A Claim Settlement Ratio of an insurer represents the total number of claim settlements against the total number of claims registered in a financial year.

Following is the calculation of the claim settlement ratio in medical insurance.

Claim Settlement Ratio = Claims settled in a year/Claims received in a year x 100

Incurred Claim Ratio represents the net amount of claims settled against the total premium received during the financial year.

Following is the calculation of the incurred claim ratio in health insurance.

Incurred Claim Ratio = Claims settled in a year/Total premium received in a year x 100

Can a medical insurance claim be rejected?

Sometimes, a health insurance claim may be rejected, and this can be due to various reasons. Here are the instances under which your health insurance claim can get rejected.

How to avoid health insurance claim rejections?

Here are some tips to avoid claim rejection against your health insurance policy.

Disclose any pre-existing conditions at the time of purchasing the health insurance policy.

Do not delay in informing the insurer as per the stipulated timeline for planned and unplanned hospitalisation.

Ensure that you obtain original medical reports, the discharge summary, bills, payment receipts, etc., since they are required for reimbursement claims

Understand the features, inclusions and exclusions, health insurance claim procedure, and waiting period.

Cashless claim facility is available only in the network hospitals mentioned in your policy.

Things to consider while applying for health insurance claims

There are specific points that you should be careful about while making health insurance claims. The following points will help in speeding up and easing the process of the claim settlement.

Don’t delay in informing the insurer whether it is a planned or unplanned hospitalisation.

Ensure that the reimbursement claim form is filled in correctly without any errors.

Learn about the non-coverage details or exclusions of the insurance plan.

Frequently asked questions

Here are some of the commonly asked questions about health insurance claims.

How do I know if I need to opt for a cashless or reimbursement health insurance claim?

Cashless claim settlement is an easy and hassle-free method of settling claims. If it is a planned hospitalisation and the treatment is available at a network hospital, one can avail of the cashless claim.. However, in case of emergencies where you don’t get time to check the list of network hospitals or if the treatment is unavailable in the network hospital, one can opt for the reimbursement claim.

What is required to file a reimbursement claim in my health insurance policy?

The original medical reports, discharge summary, medical bills, and payment receipts, along with the filled-in claim form, are required for reimbursement claims.

What would happen if the medical insurance claim is not intimated to the insurer within the stipulated time?

If you have not informed your insurer about your claim within the specified time, the chances of your claim being rejected are high.

I recently purchased a health insurance policy for my family and myself. Am I entitled to a cashless claim?

You are entitled to opt for cashless claims, provided you opt for hospitalisation in a network hospital.

What are the charges that are not included in the health insurance policy?

Some charges are not included in the policy, such as services, administrative, and costs related to an extra bed, laundry, syringes, etc. For more information about exclusions, refer to your insurance policy.

Can I file a health insurance claim online?

Yes, you can file a health insurance claim through our website or you can write to us at [email protected] Please note that is applicable only in the case of a reimbursement claim.

What is the maximum number of health insurance claims I can avail of during the policy period?

There is no limit to the number of claims you can raise during the policy period. However, the total claim amount should not surpass the sum insured amount. If the total claim exceeds the sum insured, there would be out-of-pocket expenses.

Is there a waiting period to raise the claim against my health insurance policy?

Yes, there is a waiting period in your insurance policy. Typically, the waiting period can be for 30 days before you are entitled to file a claim, except in the case of an accident. There is also a waiting period for pre-existing conditions and specific ailments. This may vary from insurer to insurer. Hence, check with your insurance company to avoid unpleasant surprises at the time of claim settlement.

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