What are the documents required to file health insurance claim

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07 Aug 2023

Here is the list of documents required for the health insurance claim process.

When the time comes to use your health insurance, including timely filing for Medicare, it is best that you know all about the process and required documents for filing a mediclaim, especially when considering mediclaim insurance beforehand. An injury or any medical emergency can leave you in a state of panic, and the last thing you want is to get your health insurance mediclaim rejected. But if you already know all about it, you can have a seamless experience during the health insurance mediclaim process.

Documents required for health insurance claim process

A health insurance claim is the request the policyholder makes to their respective insurer for the much-needed financial assistance as per the coverages provided in their health insurance policy. The process of filing a claim is simple, but where you may find difficulty is accumulating all the health insurance claim documents and putting them together.

To help you get through the health insurance claim process quickly, here’s a checklist of all the documents you need to file a health insurance claim.

1. Claim form

As soon as you need to file a mediclaim, you have to fill out the mediclaim form, which is nowadays easily available on the website of almost every insurance company. It is one of the most important mediclaims insurance you need at the time of filing the mediclaim, especially when considering mediclaim reimbursement. 

2. Medical certificate

A medical certificate is a must-have for your health insurance claim process. It is a statement issued by an authorized doctor or hospital that describes the status of your health.

3. Diagnosis report

A diagnostic report can include blood tests, urine tests, x-rays, sonography, etc., of the patient. This has to be included in the healthcare claim documents that you submit to file a claim.

4. ID proof

Any valid identification of the patient is required. It can be a PAN Card, Aadhaar Card, a driving license, or a passport. You can check this beforehand with your insurer or stay prepared with all the options to avoid any hassle in filling medical claim form as a part in your health insurance claim process. 

5. Discharge card

A discharge card for the patient needs to be attached to the other health insurance documents. It gives information about the patient, the cause of their hospitalization, and proof of their release.

6. Prescriptions and bills

Stack all the prescriptions and bills that were issued throughout the medical process together. It would be better if you arrange them in date order.

7. FIR

In the event of an accident, it is mandatory that you file an FIR first and then abide by the process of law. Make sure to submit a copy of it to your insurer as well. 

Types of health insurance claims

The health insurance claim process can be broadly categorized into two types: cashless claim and reimbursement health insurance claim. Let’s look at these processes in brief.

Cashless claim

Under a cashless health insurance claim, you do not have to pay for the treatment upfront because your insurer takes care of it for you. But to get the benefits of a cashless claim, you have to get your treatment done at one of the network hospitals listed with the health insurance company.

A cashless claim can be filed for both planned and unplanned hospitalization. In the case of the former, visit the cashless helpdesk at the hospital 2 days before the hospitalization and complete the formalities. In the case of unplanned hospitalization, visit the cashless helpdesk at the hospital within 24 hours of admission and do what is necessary.

When you file a cashless claim, your insurer sends an authorization letter to the hospital after checking your eligibility and coverage.

Reimbursement claim

If you file a reimbursement claim, you will have to make the payment upfront and then file the claim with your insurance company. This is applicable when you take treatment in a non-network hospital. During the health insurance claim form filling process, ensure that you submit all the above-mentioned documents to your insurer. You have to file a claim and submit all the documents within 30 days of your discharge.

Depending on the type of health insurance claim you raise, the documents may differ. For guidance on the best mediclaim policies and their specific document requirements, consult your insurance company when purchasing the policy.

If you do not file the claim within the given deadline, the insurer can reject your claim on technical grounds. Hence, know the time limit beforehand so you can enjoy the benefits offered by your insurer.

Things to consider at the time of buying health insurance

Coverage limit

The coverage limit of health insurance policies varies depending on how much premium you pay for it. The coverage will include the type of treatments, hospital beds, or medications that can be covered in your plan, etc. Thus, it plays an essential part in the medical claim process.

Sum insured

You must ensure that the sum insured in a policy is sufficient for your needs. Sum insured is one of the factors that the insurer considers while evaluating your health insurance claim, and if you have exhausted your insured amount, your claim may get rejected. 

Claim settlement

While taking health insurance, you must ensure the company has a smooth claim settlement process. To make a reasonable estimate, look at the claim settlement ratio of the insurance company and do a comparative analysis. Do check for the list of documents required for health insurance claims so you can collect them during your treatment. 

Network of hospitals 

Every insurance company has a diverse network of hospitals where the policyholder can get cashless treatment. This makes it easier for the policyholder to get the treatment without worrying about reimbursements. So, check the network of hospitals for hassle-free treatment. 

FAQs

Q1. How can I obtain an MLC or Medico-legal certificate for the health insurance claim process?

You can get your MLC from the hospital authorities where the patient is admitted. All the hospitals maintain an MLC register for all the cases involving accident/assault/poisoning/burn cases are registered. The police will verify this certificate upon visiting the patient. 

Q2. What are the benefits of getting a TPA for a health insurance claim?

A TPA or Third-Party Administrator will assist you while filing the health insurance claim by ensuring that all the details are filled in correctly and that you have all the necessary documents in place. Furthermore, the TPA is appointed by the health insurance company. Hence, they act as a link between the insurer and the policyholder, making the claim process a smooth ride for the policyholder. 

Q3. What medical expenses are covered in the health insurance claim?

The health insurance claim will cover different medical expenses incurred during the insurer's treatment, which are admissible under the policy. Some of the expenses that are covered are: 

  • Hospital charges (inclusive of charges for room, OT charges, etc.)

  • Fees of anesthetists, specialists, nurses or surgeons involved in the treatment

  • Cost incurred on medicines, medical tests, oxygen cylinders or blood bags

Refer to your policy document for a detailed list of inclusions and exclusions.

Q4. What is the deadline for submitting the documents required for a health insurance claim?

The deadline to submit the health insurance documents is 30 days from the date of discharge. However, it is advised to file a claim and submit all the documents as soon as possible to ensure your claim is successfully settled. 

Q5. How many times can I file a health insurance claim?

You can file a health insurance claim unlimited times unless there is a fixed limit mentioned in your health insurance policy. However, the claims are limited by the sum insured under your policy.

Q6. Is there any difference in the time period for filing pre and post-hospital health insurance claims?

The pre-hospitalization health insurance claim must be filed within 15 days from the date of discharge. However, for post-hospitalization claims, you can submit the health insurance documents until 30 days from the date of completion of treatment or before the expiration of the post-hospitalization period specified in your health insurance policy. 

To safeguard yourself and your family from any future medical emergency, choose a health insurance plan with Kotak general insurance and fulfill all your insurance needs.

References- 

https://streamlinehealth.net/cms-1500-form/#:~:text=LEARN%20MORE-,What%20is%20a%20CMS%201500%20Form%3F,-The%20term%20CMS

https://www.kotakgeneral.com/claims 

https://www.kotakgeneral.com/blog/health-insurance/what-is-a-health-insurance-claim-settlement-ratio 

https://www.kotakgeneral.com/blog/health-insurance/how-does-tpa-help-during-claim-processing-in-health-insurance

https://www.icicibank.com/blogs/health-insurance/health-insurance-documents-requirement 

https://www.policybazaar.com/health-insurance/individual-health-insurance/articles/documents-required-for-health-insurance/ 

https://www.policybazaar.com/health-insurance/individual-health-insurance/articles/documents-required-for-health-insurance/ 


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Team Kotak GIC

The content of this blog has been created and carefully reviewed by the esteemed team at Kotak General Insurance, with the sole purpose of providing valuable guidance and sharing insights on the importance of general insurance. Our objective is to assist users in making informed decisions when purchasing or renewing insurance policies for their cars, bikes, and health. Our expertly curated information aims to empower our readers with the knowledge they need to protect their valuable assets and financial interests.