Health insurance claims refer to a request raised by the policyholder of a health insurance plan to the insurance company for funds. A claim can be raised when the policyholder requires money for treatment of a minor or major illness listed in the health plan, accident, injury, or any other medical condition. A health insurance claim can be raised for any of the services offered in a health insurance policy.

How do health insurance claims work?

Health insurance claims are pretty straightforward. You can raise a claim as to and when you need funds to cover your health expenses. There are two types of claim processes:

Cashless claims

In the case of cashless claims, you can simply go to a network hospital and get treated for an illness. The insurance company deals with the hospital directly and covers your health expenses up to the extent of your policy coverage. In this case, you are only required to share your policy details with the hospital, and the insurance provider takes care of all other formalities.

Reimbursement claims

In the case of reimbursement claims, the insurance company issues you reimbursement on the basis of the actual expenses incurred. You need to raise a claim for reimbursement and submit all medical bills to the insurance company. The insurance company will review the bills and repay you for the amount spent up to the extent of your policy coverage. This can be a lengthy process sometimes, so you may have to keep an eye out on the health insurance claim status to monitor your funds.

Below are two examples to explain this better:

• Mr. A has a cashless claim policy. He gets hurt in an accident and needs emergency surgery. The cost of his surgery can be covered under his policy cover. So, he simply shares the details of his policy with the hospital, and the insurance company settles his bills with the hospital directly
• Ms. B, on the other hand, has a reimbursement claim policy. She is diagnosed with a minor health condition that requires hospitalisation for a few days. She incurs the cost of hospitalisation, room rent, medicines, and other charges out of her own pocket. After her treatment is over, she contacts her insurance provider, submits the bills, and receives the funds

Documents required to make a health insurance claim

You may need the following documents to make a health insurance claim:

• Identity proof
• Policy document
• Medical reports of your illness
• Hospitalisation papers along with dates
• Medicine bills
• Ambulance bills
• Discharge papers
• Any other costs related to your treatment

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