What is the Process of Health Insurance Claim?

Nowadays Health Insurance claim procedure has become simple with most of the Insurance Companies opting for an easy and speedy procedure. Depending on the rules and regulations of the Insurance Company the client has to act accordingly.

The procedure for claim differs in case of planned and emergency hospitalization. In case of planned hospitalization as in the case of inpatient hospitalization the client can avail for cashless service where the treatment is free. In emergency hospitalization, the client has to pay for the bill and can later claim for the medical expenses incurred.


Following are the steps that must be taken for the complete process of Health Insurance claim:

  • The Health Insurance claim form must be collected from the respective Insurance Company office, or agents, or online. The following information should be properly mentioned in the claim form:
    • Policy holder’s name
    • Policy number
    • Date and time of diagnosis of the disease
    • Type of disease
    • Location of the disease
    • Contact details
  • The claim form must be filled in accordance with the company’s terms and conditions and all the necessary documents should thoroughly checked and attached.
  • The completed claim form must be submitted to the company within the maximum time period.
  • All the medical receipts must be kept in original and be kept in chronological order by the client. These should be produced as and when required. The bills prior to 30 days before hospitalization and 60 days after hospitalization should be preserved as these are relevant and are usually reimbursed by the Insurance Company.
  • All the documents relating to the treatment should be submitted in original and a set of Photostat copies should also be submitted along with the original. The client must keep a duplicate copy of the original as this is vital for establishing the proof of the treatment in case the originals are misplaced or lost.
  • In case of a surgery the information regarding the surgeon’s consultation fees, surgery fees, operation theatre charges should be provided to the Insurance Company.
  • A certificate is given by the concerned Doctor or the Surgeon that the patient is cured or on the way to recovery. This Certificate must to be provided to the Company.
  • After all the bills have been paid the doctor sends the bill to the Insurance claims processing center. The processing center gathers all the relevant information of the patient like the intake forms, patient information sheet for proper services documentation.
  • This information is then tallied with the explanation of benefits given by the client and the policy is then perused to see which of the services the policy covers. The relevant amount of money is then paid to the client.
  • The Health Insurance Inception details must be provided to the Third Party Administrator (TPA) for validation and verification purpose. The Customer care executive in the TPA deals with the handling of these kinds of files.