Health insurance claim settlement process - PolicyBoss

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Health Insurance Claim Settlement Process
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24/7
Hours Days
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WHAT IS A HEALTH INSURANCE CLAIM?
A Health Insurance claim is a request made by
policyholder to the health insurer to avail the
services covered under the insurance policy.
TYPES OF CLAIM SETTLEMENT PROCESS

• CASHLESS
• REIMBURSEMENT

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CASHLESS CLAIM SETTLEMENT PROCESS
There are two types of cashless claim settlement
process.
01. PRE-PLANNED HOSPITALIZATION

• 1. Recommended that you inform the health insurer
  2-3 days prior to hospitalization
• 2. Inform the Third Party Administrator (TPA) and
  submit the required documents
• 3. Insurer investigates your documents and case
  and inform you about eligibility
• 4. Insurer pays the bills as per approved claim
  amount

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02. EMERGENCY HOSPITALIZATION

• 1. Call up the insurers customer care and get
  details on nearest empanelled hospital
• 2. Get hospitalized and submit your health
  insurance details to hospital authorities
• 3. Hospital sends your claim request along with
  required documents to Third Party
  Administrator (TPA) of insurer
• 4. TPA studies your case and upon approval,
  settles the bill amount with hospital

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REIMBURSEMENT CLAIM SETTLEMENT PROCESS
Get admitted in Hospital Pay the bills and
collect the documents at the time of
discharge Submit all the required documents and
?lled application form to the Third Party
Administrator (TPA) of insurer TPA investigates
your claim As per amount of claim approved,
reimbursement is made directly to your bank
account
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REQUIRED DOCUMENTS
Duly ?lled in Claim Form Medical Certi?cate/Form
signed by doctor Prescriptions/Cash Memos of
pharmacies/Hospitals Investigation
reports Original bills and reports Original
Discharge summary/card FIR/Medico-Legal
Certi?cate (in accidental cases)
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