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A health insurance plan is a product that provides financial protection for the policyholder against medical expenses associated with a wide range of illnesses or injuries. It can pay for the expenses incurred due to a planned or unplanned treatment.
There are two ways a policyholder can raise a health insurance claim, the cashless and the reimbursement methods. While both methods provide the required financial benefits, there are a few differences between the two types of health insurance claims and their related procedures. And understanding these differences is vital to make a valid health insurance claim.
Before we get started, let us understand what a health insurance claim means and its process.
What Is a Health Insurance Claim?
A health insurance claim is a process by which the policyholder raises a request to their insurance provider to avail the financial benefits and other related facilities covered under their health insurance policy.
The policyholder will raise the claim by providing the details of the medical expenses with supporting documents. Upon receipt, the insurance provider will analyze the request and process the health insurance claim to provide the applicable benefits. With the advancement in technology, raising health insurance claims online is possible. It is a relatively simple, user-friendly, and less time-consuming process.
How Does the Health Insurance Claim Process Work?
The policyholder will raise the claim with the insurer by filling out the claim request form and providing the supporting documents. The health insurance claim can either be for a cashless or reimbursement claim benefit.
Types Of Health Insurance Claims
Health insurance providers offer the said two types of health insurance claim processes to help individual policyholders benefit based on their specific needs.
Cashless claims
The cashless claim benefit is applicable for policyholders preferring to take medical treatment in the network of hospitals the insurance provider provides. A network hospital partners with the insurance company or TPA to provide cashless claim benefits. The list of network hospitals is available on your policy document or on the insurer’s website, TPA portal, TPA website.
Based on the hospitalisation and medical expenses, the policyholder will have to raise a claim request to the insurance provider. They will have to get the approval of the insurance provider, or an authorized Third-Party Administrator (TPA) appointed by the insurer, to begin with the treatment.
After receiving the request, the insurer will verify the details with the hospital and pay the expenses directly to the hospital.
Some of the key points related to cashless claims are:
- Health insurance providers offer a good network of hospitals with the best quality treatment to ensure that the policyholders receive timely and reliable treatment for faster recovery.
- The network of hospitals will be spread out in different places across the country for easy access. Click the link below to check the network hospitals.
Reimbursement claims
The reimbursement claim benefit applies to policyholders preferring to take medical treatment in a hospital of their choice.
The policyholder will pay the bills from their pocket for the hospitalisation and medical expenses. Further, they will have to raise a claim request to the insurance provider for reimbursement by providing the necessary bills and invoices.
Upon receiving the request, the insurer or TPA will verify the details and the supporting documents and reimburse the expenses as per policy coverage.
Difference Between Cashless and Reimbursement Claims
Factors |
Cashless Claims |
Reimbursement Claims |
Meaning |
The insurer will pay the policyholder’s medical expenses directly to the hospital. |
The policyholder will pay the respective medical bills, and the insurer will reimburse the same later. |
Claim process |
The policyholders must inform the insurer or TPA, choose from their network of hospitals, and raise a claim request. |
The policyholders must get the treatment done in a hospital of their choice and pay the respective bills. Further, they must provide the medical records and the applicable bills to the insurer and raise a claim request. The insurer will verify the claim request and approve the same. |
Approval before treatment |
The insurer will have to approve the claim request before the policyholder gets the treatment from the hospital. The stipulated time will vary for unplanned and emergency treatment. |
The policyholder need not get the approval before the start of the treatment. However, it is best advised to inform and verify the health insurance coverage for the specific scenario. |
Applicable hospitals |
The policyholder can choose any hospital from the network of hospitals provided by the insurance provider. |
The policyholder can choose any hospital. |
Documents required |
The policyholders must fill out the form for health insurance coverage provided by the Third-Party Administrator at the hospital and produce the same to the TPA with the claim request. |
The policyholder will have to provide all the documents related to the health condition, treatment taken, payments made, etc. It can include diagnostic test reports, discharge summary, payment receipt, etc., |
Claim settlement |
The insurer will directly pay for the hospitalization and the medical expenses directly to the hospital on behalf of the policyholder. |
The policyholder will pay the respective bills to the hospital and provide the receipts to the insurer. The insurer will reimburse the expenses later to the policyholder. |
Time taken for settlement |
Cashless claims are approved within the stipulated TAT of 2 hrs. for each transaction |
As reimbursement claims are initiated after the treatment, the insurer will have to verify and process the requests. It can take up to 45 days for the settlement |
Health Insurance Benefits with Life Insurance Riders
Adding optional health riders^ to your life insurance policy can offer very similar benefits to health insurance, such as critical illness coverage, hospitalisation benefits, coverage for major and minor illnesses and injuries and more. While your life insurance plan does offer adequate coverage to your beneficiaries against death, the riders are designed to cover very specific risks, events and also health insurance needs.
These riders can be added to your life insurance policy for an additional premium to help boost your base policy coverage. If you add health riders to your life insurance plan to enhance the policy coverage, understand if there is a different set of documents or a separate claims process involved in claiming the rider benefits.
Frequently Asked Questions
What are the different types of Health Insurance claims?
The two types of claims in health insurance are cashless claims and reimbursement claims.
How long will it take for the reimbursement claim to be processed?
The reimbursement claim process can take 45 days based on the specific request and health expenses.
When should I inform my insurance provider for a cashless claim for a planned hospitalisation?
The insurer should be informed at least 72 hours before the planned hospitalisation for the cashless claim.
In what scenarios can my claim get rejected?
Health insurance claims can get rejected in the following scenarios:
Any pre-existing health condition is disclosed during policy inception.
Delay in filing the claim and not informing the insurer within the stipulated time.
When supporting documents such as bills, discharge summaries, medical reports, etc., are not provided for reimbursement claims.
When a cashless claim benefit is opted for by the policyholder and the treatment is taken in a hospital, not in the network of hospitals of the insurance provider.
When filing a claim without understanding the inclusions and exclusions of the cashless or the reimbursement claims.
Whom do I contact for Health Insurance Claims?
You can contact the help desk of the TPA for health insurance claims primarily for any clarifications and processes.
What is a health card?
A health card is an identity card for the health insurance policy the insurance provider provides. It helps register for the claims and keep track of the previous settlements.
Can I file a health insurance claim online?
Yes, a health insurance claim can be filed online with the respective insurance provider for reimbursement claims.
What is the maximum number of health insurance claims I can avail of during the policy period?
There is no limit on the number of claims. However, the total claim expenses should not exceed the total sum insured under the health insurance policy.
When can we claim health insurance?
The health insurance claims can be made:
Before 72 hours for planned hospitalisation for cashless claims
Within 24 hours of emergency hospitalisation for cashless claims
Within the stipulated time specific to the insurer, such as 2 to 4 weeks from the treatment/hospitalisation for the reimbursement claims
Can I claim health insurance twice?
Yes, You can raise claims as long as your sum assured is not exhausted.
Can I claim health insurance every year?
Yes, you can claim health insurance every year.
Disclaimer
Insurance cover is available under the product.
^Riders are not mandatory and are available for a nominal extra cost. For more details on benefits, premiums, and exclusions under the Rider, please contact Tata AIA Life's Insurance Advisor/Intermediary/ branch.
The products are underwritten by Tata AIA Life Insurance Company Ltd.
The plans are not a guaranteed issuance plan, and it will be subject to Company’s underwriting and acceptance.
For more details on risk factors, terms and conditions please read the sales brochure carefully before concluding a sale.
Every effort is made to ensure that all information contained in this document is accurate at the date of publication, however, the Tata AIA Life shall not have any liability for any damages of any kind (including but not limited to errors and omissions) whatsoever relating to this material.
L&C/Advt/2023/Jun/1894
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