Claim Health Insurance

How to Claim Health Insurance in India

If you are planning to purchase a health insurance policy for family or health insurance for parents you must do some research to understand important points to keep in mind while getting health insurance for your loved ones. Because in health insurance you must know what is covered and how the process works to avoid complications at the time of claim.  

Let’s looks at important points to consider while purchasing health insurance –

  • Sum insured – Choose the sum insured amount that is enough to meet the medical expenses by keeping ever-inflating medical costs in mind.  
  • Premium – Premium is a fixed amount paid on regular basis to keep the policy active. Generally, this amount is paid annually in health insurance. In recent guidelines, IRDAI has advised health insurance providers to introduce EMI option.
  • Health Insurance Company’s Reputation – It is important to purchase health insurance from a reputed organization for better service.
  • Network Hospitals Coverage For Cashless Treatment – Cashless treatment options will be available at network hospitals associated with the insurer and you must select a health insurance policy from an insurance company that has a wide network of hospitals.
  • Room Rent Limit – Select a plan with sufficient room rent cover. Because other bills also can vary based on room type selected in the hospital.
  • Sub-Limits On Various Expenses – Check if there are sub-limits on different services provided by the hospital.
  • Co-payments if there are any – Some plans would have a co-payment normally or if the insured person’s age is above 60 years.
  • No-Claim Bonus – Some policies offer additional coverage in a consecutive year if there is no claim in a year.   
  • Restore Benefit And Recharge Benefit – Some plans offer restoration of cover to full limit if the full or partial cover gets exhausted before the completion of the policy year.
  • Waiting Period And Disease Exclusions – Some plans would have a waiting period if there are any existing health issues at the time of purchasing the policy.
  • Pre-Hospitalization And Post-Hospitalization Expenses – Coverage for pre-hospitalization and post-hospitalization expenses is covered in the health insurance plan. Selecting a plan that offers maximum coverage is a good idea.  
  • Domiciliary Hospitalization – Some plans cover treatment costs for home hospitalization too. Check for such an option if you wish to. But read conditions in the policy document.   
  • Daycare Procedures Cover – Daycare procedures are treatments that don’t require a hospital stay. The patient can leave the hospital after a few hours of treatment. Due to new medical technology such treatments require less treatment time but cost high. Choose a plan that covers such cover too.
  • Alternate Treatments Coverage Like AYUSH – Some plans cover the expenses of treatments like Ayurveda, Unani, Sidha, and Homeopathy too. If you need coverage of such treatments, choose a plan with the AYUSH option.

Mentioned above are features and benefits offered by a health insurance policy which may vary depending on the plan and the company. Based on your requirement and affordability you should compare the available plans offered by different companies to arrive at the best choice.

Apart from these features, it is important to look for the claim percentage of health insurance companies because it is important that your health claim gets approved at the time of hospitalization without much hassle.

Read More: Health Insurance Plans For Family In India

What Is Claim Ratio in Health Insurance?

In simple terms, a claim ratio in health insurance is the percentage of claims settled by the insurance company out of total claims it gets in a policy year. The claim settlement ratio of the insurance company is an essential element that can reflect the reliability of the insurance company and the success rate of claim settlement that it does to its customers.   Health insurance companies mention their claim settlement ratio details in their documents or their website. IRDAI also releases an annual report of all health insurance and general insurance companies which can be accessed by the public. So if you wish to know the claim settlement ratio of a health insurance company, you can check from the IRDAI website link mention in the reference section at the end of this article. For easy understanding here is the table of claim settlement ratio fetched from the IRDAI Annual Report.

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GENERAL INSURERSNet Earned Premium (Crore) Claims Incurred (Net) (Crore) Incurred Claims Ratio (%) 
Acko General Insurance Ltd.29.537.0024%
Bajaj Allianz General Insurance Co. Ltd.1865.881591.4885%
Bharti AXA General Insurance Co. Ltd.222.60197.1289%
Cholamandalam MS General Insurance Co. Ltd.428.50151.2635%
DHFL General Insurance Limited46.9621.6346%
Edelweiss General Insurance Co. Ltd.22.7726.26115%
Future Generali India Insurance Co. Ltd.238.11174.5773%
HDFC ERGO General Insurance Co. Ltd.1053.17656.0062%
Go Digit General Insurance Ltd.14.531.5611%
ICICI Lombard General Insurance Co. Ltd.1826.991396.8076%
IFFCO Tokio General Insurance Co. Ltd.838.65854.71102%
Kotak Mahindra General Insurance Co. Ltd.37.7017.8047%
Liberty Videocon General Insurance Co. Ltd.151.04123.3082%
Magma HDI General Insurance Co. Ltd.54.8049.5790%
Raheja QBE General Insurance Co. Ltd.0.130.0431%
Reliance General Insurance Co. Ltd.893.79836.1094%
Royal Sundaram General Insurance Co. Ltd.306.50185.5061%
SBI General Insurance Co. Ltd.978.67509.2152%
Shriram General Insurance Co. Ltd.3.571.8752%
Tata AIG General Insurance Co. Ltd.665.72518.5378%
Universal Sompo General Insurance Co. Ltd.133.40122.9992%
STANDALONE HEALTH INSURERSNet Earned Premium ( Crore) Claims Incurred (Net) ( Crore) Incurred Claims Ratio (%) 
 Aditya Birla Health insurance Co. Ltd. 348.23204.1159%
Apollo Munich Health Insurance Co. Ltd.1672.901047.0963%
CignaTTK Health Insurance Co. Ltd.392.52243.1462%
Max Bupa Health Insurance Co. Ltd.659.48355.6454%
Reliance Health Insurance Ltd.1.360.1813%
Religare Health Insurance Co. Ltd.1091.20602.6755%
Star Health and Allied Insurance Co. Ltd.3662.372297.5963%
Incurred Claim Ratio – Data Extracted from IRDAI Annual Report 2018-2019

1) How companies typically settle a health claim

The process of claim settlement depends on the type of hospitalization. The claim process varies if the hospitalization is planned or emergency admission.

health insurance

Claim settlement in case of Planned Hospitalization

In case of planned hospitalization, the insured person should get pre-authorization from the insurance company at least 48 hours in advance before admitting to the hospital. This is done by contacting their customer support or by mail communication or by filling the form on their website. These details are mentioned in the policy document.  

Once the insurance company accepts and registers the claim then the customer can obtain a cashless facility at their network hospital. The customer has to follow a non-cashless procedure if the pre-authorization is not approved. The insurance holder has to pay bills out of his pocket and claim later through the reimbursement process.

For simple understanding, the steps involved in the planned hospitalization claim settlement process are typically like below.

  • The insured person informs the Insurance Company about the planned hospitalization. It may be done online or by contacting the customer support team as mentioned in the policy documentation. If the company does it through TPA, then the claim process is handled by TPA. The insured person has to approach the TPA to inform about hospitalization.
  • The insurance company can either accept or reject the pre-authorization. In case of approval, the insured person can get cashless treatment at the network hospital.
  • On approval, the insured person admits to the network hospital and gets treatment.
  • Once the treatment is finished, the insured person gets discharged by paying minimal bills that don’t count under the health insurance claim.
  • Later the hospital shares all the detailed billing with the insurance provider or the TPA if they are involved.
  • Claim settlement is done by the insurance company directly to the hospital if they have in house claim settlement department. Or they will settle the claim to the hospital through TPA if they are involved.

Claim settlement in case of emergency Hospitalization

In case of emergency hospitalization, the pre-authorization is needed after the admission into the hospital. In an emergency, the insured person can admit to a network hospital nearby and someone from the family should inform the insurance company about the hospitalization within 24 hours of hospitalization to get approval.

For simple understanding, the steps involved in the emergency hospitalization claim settlement process are typically like below.

Read More: How To Choose Best Health Insurance Policy For You?

  • An insured person gets admitted to the nearest network hospital
  • Anyone from the family should inform the insurance company customer care or the TPA if that is involved within 24 hours from the hospital admission.
  • The claim settlement department in the insurance company or the TPA verifies the case that if the condition and treatment is covered and the claim is applicable.
  • Approval for treatment is given by the insurance company to the hospital. An authorization letter is issued by the insurance company to the hospital.
  • Once the approval is given the patient gets treatment and is discharged after clearing the non-medical and non-admissible expenses.
  • Hospital shares all the necessary documents and bills with the claims department in the health insurance company or with TPA if the insurer has TPA.
  • Insurance company dose the claim settlement directly to the hospital or through TPA in case the insurance includes TPA.     

2) What are the different modes of claim settlement (cashless vs reimbursement), TPA vs in-house claim process, etc. 

Claim settlement is done in two ways called cashless claim and reimbursement. The mode of claim settlement depends on the selection of the hospital for treatment.

Cashless Hospitalization VS Reimbursement

If you join a network hospital recognized by the insurer and if it allows cashless hospitalization then it will be a cashless claim settlement.

In case if you have to join a hospital that is not listed as a network hospital by the insurer then you have to settle the hospital bills first out of your pocket and later claim the same from the insurer. This process is called reimbursement.

TPA VS In-House Claim Process

When it comes to the claim settlement process, the health insurance claim applied by the insured person may be settled in two ways which depend on the insurance company. Some well-established companies have their in-house claim process department whereas some companies do this job through TPA associated with them.

TPAs are third-party administrators who act as middlemen between the insured person and the insurance company and their role is to help customers in processing the claim.

Some insurance companies will have a tie-up with TPA to handle the claim procedures. The role of TPAs in health insurance is they only help in processing the claim. The decision making about claim settlement is only done by the health insurance company.

Roles of TPA (Third Party Administration) include

  • Reviewing the pre-authorization request from the insured person that if the suggested medical treatment is covered or not in his insurance plan.
  • Help customers to choose the right network hospital for cost-effective treatment.
  • Enrolling the IDs of the insured person for cashless hospitalization after the acceptance of the pre-authorization request.
  • Claim processing and settlement.

If the insurance company has an in-house claim settlement department, the claim settlement will be done through the in-house claim process.  

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3) What are some common challenges that may come at the time of claim settlement

For a successful health insurance claim, care should be taken right at the time of filling the proposal form while purchasing the health insurance policy. It is advised to mention if there are any existing health conditions while purchasing health insurance.

Let’s look at some possible challenges that may come at the time of claim settlement.

Policy not being active

If you have a health insurance policy, it is important to keep it active. Renew your health insurance on-time at every renewal date without missing a successful claim. 

Failing to intimate on-time for preauthorization

Not informing the insurance company about hospitalization on time may cause delay or rejection of claim settlement. For a successful claim settlement of health insurance, the initial step is to inform the insurance provider about your hospitalization. There will be different options to intimate the insurer for getting pre-authorization. It can be done by calling customer care, mail communication, or contacting the TPA if the company does it through its TPA.   

Miscommunication

Any wrong entry of details in the claim form can lead to claim rejections. Verify all the details mentioned in the claim form before signing and submitting it. Details of policy, policyholder details, treatment details, billing details, etc. should all be error-free for a successful claim.   

Reimbursement claim

If it is a reimbursement claim, all the original bills should be enclosed along with the claim form. According to IRDAI guidelines, the insurance company should finalize the claim process within 30 days from the date it receives the final supporting documents. Any delay in receiving the supporting documents can lead to delay. 

Unawareness about the terms and conditions

Another important thing that can lead to issues in claim settlement is not reading the policy documentation to understand terms and conditions properly. Mistakes can happen in the claim procedure if the insured person is not clear about the policy like what is covered and what is not.

4) What are your options if your health insurance claim is getting rejected

A health insurance claim can get rejected due to various reasons, so you must understand the reason for claim rejection to address the issue.

Some common reasons for the claim rejection can be:

  • Lack of sufficient information in claim application.
  • Incorrect information about the insurance details.
  • Lack of pre-authorization or delay in informing the insurance provider about hospitalization.
  • Wrong entry of treatment code in the claim form. Every medical treatment will have a code and if that is not entered properly, that may be one reason for claim rejection.
  • Delay in filing the bills by the hospital can also cause delay or rejection of claim settlement.
  • If the insurance provider considers that conducted treatment is not necessary to treat your health issue.
  • If there are any payments pending that have to be cleared by the insured person such as co-pay or deductibles.     

Option when a health insurance claim is rejected:

Fortunately, in case the claim gets rejected, the options are mostly in favor of the insurance holder. IRDAI is regulatory which monitors and regulates the insurance companies. It has made changes to facilitate an easy process of appeal.

When the claim gets rejected, the insured person can appeal for verification either through an internal review procedure which is done within the insurance company or by an external review done by an external regulatory body.

What is an internal appeal

In an internal appeal, the insured person can request the insurance company to review the claim once again. If there are errors in filing the claim form, the insured person can correct the errors and provide the missing information in the claim application and resubmit the claim with the supporting documents if there are any missing documents to support the claim.

Similarly based on the reason for claim rejection the insured person can provide the missing information specific to the reason for rejection and resubmit the claim.     

Most likely the claim gets accepted if the claim is genuine and all the details are mentioned in the claim form without any errors and all the support documents are submitted.

What is an external review

If the claim is rejected even after the second appeal and if the claim appeal is genuine or if the insured person doesn’t wish to deal it with the insurance company, in such case insured person can ask an independent third party to review the claim rejection decision. IRDAI has streamlined the claim settlement redressal procedure for the convenience of insurance holders.        

5) Why you should declare your past medical history very clearly to avoid any issues later at the time of claim settlement?

It is important to mention details about any existing health issues and details of any treatment taken to treat the health condition at the time of filling the proposal form while purchasing the health insurance. Non-disclosure of medical history is considered as an attempt to cheat the insurance company and this can become a major point to reject the claim. So it is advised to disclose the health issues and lifestyle habits like alcohol or tobacco consumption in case the insured person has any such.

Most likely these days many people suffer from lifestyle diseases like diabetes and hypertension. These two health issues can lead to more complications over a period. So if the insured person has any such health issues and if he misses to declare them in the proposal form while buying the health insurance no matter if he does it willingly or by mistake, at the time of claim settlement if it is found that any medical history is not disclosed properly at the time of proposal, the insurance company has all rights to reject the claim as per general terms and conditions mentioned in insurance documents.

If the insured has any previous medical history, it is advised to keep all the supporting documents handy and share them with the insurance company while claiming the settlement.  

6) Should you always claim – when should you not claim to retain the benefits like renewal bonus? 

The key purpose of health insurance is to provide financial freedom when there is a medical emergency that needs heavy financial support which is out of the affordable limit of the insured person in general.

So it is advised to decide wisely when to claim the insurance and when not. Ideally one should not be claiming health insurance for minor medical expenses that are affordable. This is specifically for those plans with a no-claim bonus feature. By not using the health insurance for minor medical bills the insurance holder can gain benefits like a no-claim bonus which allows covering more in the consecutive year if there are no claims in a year.      

7) How can you raise a grievance for a claim-related dispute with the insurer? 

If the policyholder feels that the claim rejection is unfair, there are various options to lodge complaints against it.

Write a Complaint to the Insurer

The initial approach to raise a dispute in case of claim rejection is to lodge a written complaint to the insurer’s grievance redressal officer. Contact details of the grievance redressal cell are generally available in the policy documents and on the insurance company website.

The insurance holder will get an acknowledgment against the complaint. The complaint should be addressed by the insurance company within 15 days after receiving the complaint. But if there is no response or if the policyholder is not satisfied by the response, he can complain with IRDAI.          

Contact IRDAI

Next step in claim-related complaints is to approach IRDAI if there is no response from the insurance company’s redressal department. Insurance holders can contact IRDA Grievance Call Centre to lodge their complaints and know the status of their complaints.  

Ombudsman or civil court

If the insurance holder is still not satisfied with the result, he can approach the insurance ombudsman and complain or can file a civil complaint in consumer court.       

8) What are your legitimate rights as an insured

As an insurance holder, you should be aware of your legal rights. Let’s look at some

Right to Cancel the Policy

The insurance holder can cancel the policy if he wishes within 15 days from the receipt of the policy documents if he is not satisfied with the policy or disagrees with the terms and conditions of the policy.

Right to get a full refund of the premium paid

The insurance holder is entitled to get the full refund if he wishes to cancel his health insurance within the stipulated time after receiving the policy documents. Nominal service charges may be excluded in refund depending on the insurance provider.

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