Most health insurance policyholders are clueless about the claim process. The policy terms can be confusing. The documentation and other nitty-gritties only add to the confusion. Here we decode the entire health insurance claim process for your benefit.

Health insurance claim?

What is health insurance claim? Let us first understand this. A health insurance plan is a contract between the insurance company and the policyholder. The policyholder pays a fixed premium to the insurance company which promises to cover all medical bills, to the extent of sum insured, during hospitalisation of the insured person. While seeking the insurance amount, the policyholder must inform the insurance company about the hospitalisation and submit valid documents. This process is referred to as claiming health insurance.

How to file a health insurance claim? ?

One can make a claim under a health insurance plan in two ways. First, on a cashless basis and second, on reimbursement basis.

Cashless claims: The primary condition for claiming the cashless facility is that the policyholder’s treatment must be at a network hospital of the insurer. As per the Insurance Regulatory Authority of India (IRDAI), “You have to seek authorisation for availing the treatment on a cashless basis as per procedures laid down and in the prescribed form.”

The regulator further asks you to “read the policy document as soon as you receive it to familiarise yourself with the process rather than wait for a claim to arise”.

Reimbursement claims: Some policies offer reimbursement of medical expenses incurred by the policyholder. In this claim process, the policyholder has to first clear the hospital bill. Later, the insurer reimburses it after examining the documents.

IRDAI guidelines advise the policyholders to read the clause relating to claims in your policy document as soon as you receive it. This is to ensure that you understand the procedure and the documents required for making a claim on reimbursement basis. When a claim arises, you should inform the insurance company as per procedures required.

After hospitalisation, you have to ensure that you obtain and keep the documents such as claim form, discharge summary, prescriptions and bills ready. You should submit them to the insurers while raising a claim.

If you have bought a health insurance plan from SBI General Insurance, here are a few things that you should know:

The company will start the disbursement process only after the submission of all required and necessary documents.

You can claim reimbursement of pre-hospitalisation expenses as well, along with the refund of main hospitalisation costs.

If the company finds some claims unreasonable, it will reject them.

What are the documents required? ?

Apart from filling the claim form with the necessary information, one also needs to submit valid documents to make a claim. The documents needed are explained here:

• Valid photo identity card such as Aadhaar, PAN and driving licence
• Original discharge card or discharge certificate
• Copies of prescription for diagnostic test, treatment advice and medical references
• Original set of investigation reports
• Itemised original hospital bill and receipts, hospital and related original medical bill, pharmacy bills in original with prescriptions

If the claim is approved, i.e., all documents are verified, then the entire amount will be transferred to your account by SBI General Insurance within 30 days. If the company rejects the claim, it will inform the policyholder about the same.

Disclaimer: The above information is indicative in nature. For more details on the risk factor, terms and conditions, please refer to the Sales Brochure and Policy Wordings carefully before concluding a sale.