Insurance Claims

Medical Insurance Claims: A Complete Guide

A medical insurance claim is a request for payment submitted to an insurance company for healthcare services received by the policyholder. The process ensures that medical expenses are covered as per the policy terms.

Types of Medical Insurance Claims

  1. Cashless Claims (Preferred Provider Network – PPN)

    • Treatment is availed at a network hospital, and the insurer settles bills directly with the hospital.

    • No upfront payment is required (except for non-covered expenses).

  2. Reimbursement Claims

    • The policyholder pays the medical bills first and later submits documents for reimbursement.

    • Common when treated at a non-network hospital.

  3. Pre-Authorization Claims

    • Required for planned hospitalizations or major surgeries.

    • Approval must be obtained before treatment to ensure coverage.

Steps to File a Medical Insurance Claim

A. Cashless Claim Process

  1. Choose a Network Hospital – Verify if the hospital is in the insurer’s network.

  2. Inform the Insurer – Notify the insurance company before hospitalization (for planned treatments) or within 24 hours (for emergencies).

  3. Submit Pre-Authorization Request – Fill out the hospital’s insurance form and provide required documents (ID proof, policy details, doctor’s recommendation).

  4. Approval & Treatment – The insurer reviews and approves the claim; treatment proceeds without upfront payment.

  5. Final Settlement – The insurer pays the hospital directly (except for any deductibles or co-pays).

B. Reimbursement Claim Process

  1. Pay Medical Bills First – Settle expenses with the hospital/clinic.

  2. Collect Documents – Keep bills, prescriptions, discharge summary, diagnostic reports, and payment receipts.

  3. Submit Claim Form – Fill out the insurer’s reimbursement form and attach supporting documents.

  4. Claim Review – The insurer verifies the claim (may request additional details).

  5. Reimbursement – Approved amount is credited to your bank account (usually within 15–30 days).