A guide to health insurance claims

Navigating the health insurance claims process doesn’t have to be stressful. With the right information, you can ensure a smooth experience.This article will provide insights into pre-purchase and post-purchase stages, supported by the latest updates from the Insurance Regulatory and Development Authority of India (IRDAI).

Before Buying a Health Insurance Policy

1. Understand Your Policy

Before purchasing a policy, go through the coverage details, waiting periods for pre-existing conditions, and cost limits like room rent caps. The Customer Information Sheet (CIS) from IRDAI provides an easy-to-read summary of these terms.

2. Check Claim Settlement Ratio & Co-Payment Terms

Look at the insurer’s claim settlement ratio to understand how reliable they are in settling claims. Also, check if there’s a co-payment clause, which means you’ll have to bear part of the cost during claims.

3. Consider a No-Claim Bonus (NCB)

Some policies offer a No-Claim Bonus, increasing your coverage if you don’t make any claims in a year. This can be useful in the long run.

4. Pay Attention to Room Rent Limits

If your policy has a low room rent limit, you might have to pay extra if you choose a more expensive hospital room. Opt for a policy with a higher limit or no cap to avoid unexpected costs.

During the Claims Process

1. Opt for Network Hospitals for Cashless Claims: Choosing a network hospital significantly eases the claims process by enabling cashless treatment, where the insurer directly settles bills with the hospital. For emergency hospitalisations, notify the insurer or Third-Party Administrator (TPA) within 24 hours. For planned admissions, inform them at least two to three days in advance.
2. Keep the Documentation Ready: Accurate and complete documentation is crucial for a successful claim. Ensure you collect and organise:
   • Doctor’s prescriptions
   • Lab test reports
   • Detailed hospital bills and discharge summaries For accident-related claims, precise documentation becomes even more critical to prevent delays or rejections.
3. Leverage Relationship Manager Support: Many insurers and brokers provide dedicated relationship managers who can assist with the claims process, including documentation and claim filing. Seek their guidance for faster and smoother resolutions.
4. Be Transparent with Information: Always make full and honest disclosures when purchasing a policy and during claims. Concealing pre-existing conditions, family medical history, or past surgeries can lead to claim rejections. For example, a claim involving a condition linked to undisclosed health issues may fall under the pre-existing waiting period clause and be denied.
5. Room Rent Compliance: Avoid choosing rooms beyond your policy’s room rent limits. Opting for higher-priced rooms can result in additional expenses for doctor fees and medicines. Always confirm your room eligibility with your insurer or broker.
6. Get Cost Estimates and Advice for Planned Treatment: Before undergoing planned treatments, get cost estimates from multiple hospitals and consult your insurer or broker to select one that aligns with your policy coverage. This helps minimise out-of-pocket expenses and avoids disputes with insurers over charges deemed unreasonable.
7. Avoid Unnecessary Hospitalisation: Ensure outpatient care is not wrongly converted into in-patient hospitalisation. For genuine cases, gather supporting proof like diagnostic reports and doctor’s certificates to validate your claim.
8. Stay Updated with Digital Tools and Technological Advancements: Embrace the digital features offered by insurers, such as mobile apps for claim filing and status tracking. These tools provide a faster and more transparent claims experience.
9. Seek Assistance When in Doubt: If you face challenges during the claims process, contact your insurer’s helpline or customer service. Unresolved issues can be escalated to the insurance ombudsman for resolution.

By thoroughly understanding your policy, selecting network hospitals, maintaining proper documentation, leveraging relationship manager support, and staying proactive with hospital choices, you can navigate the health insurance claim process confidently. Additionally, platforms like PhonePe can help you compare policies from different insurers in one place, making it easier to find the right coverage for your needs.

Note to the reader: This article has been produced on behalf of the brand by HT Brand Studio and does not have journalistic/editorial involvement of Mint.