With the increasing healthcare costs, having mediclaim insurance provides a financial cushion, ensuring you don’t have to bear hefty medical bills out of pocket. Knowing how to file a mediclaim insurance claim effectively is important, as it can be the difference between a smooth process and potential delays. Here’s a step-by-step guide to help you through it.
Steps to File a Mediclaim Insurance Claim
Step 1: Understand Your Mediclaim Policy
The first step in filing a mediclaim insurance claim is to be fully aware of your policy’s coverage details. Every mediclaim insurance policy has different inclusions and exclusions, such as coverage for specific ailments, types of hospitalisations (like cashless and reimbursement), and room rent limits.
Checklist:
- Review policy documents carefully
- Understand what’s covered under your policy
- Note any sub-limits on specific treatments or room rentals
Being well-informed will help streamline the claim process and avoid surprises later.
Step 2: Immediate Intimation to the Insurer
If a doctor advises you to be hospitalised, you must notify your insurer immediately. You can do so by calling their helpline, sending an email, or, if available, through an online portal.
- Cashless Claim: Intimation for planned treatments should be done at least 3 days before hospitalisation.
- Reimbursement Claim: For emergencies, notify the insurer within 24 hours of hospitalisation.
Step 3: Opt for Network Hospitals (For Cashless Claims)
Choosing a network hospital is essential for cashless mediclaim insurance claims. Network hospitals have direct agreements with insurance providers, enabling cost-effective treatment without upfront payments from your end.
- Access the List: Check the list of network hospitals your insurance company provides.
- Pre-Authorisation: Fill out the pre-authorisation form at the hospital’s TPA (Third-Party Administrator) desk. The form will be sent to the insurer for approval.
If you have to opt for a hospital outside the network, you can file for reimbursement after discharge.
Step 4: Preparing for Hospitalisation (Documents and Essentials)
Having the right documents is essential for a convenient renew health insurance policy claim. Whether you are going for cashless or reimbursement claims, gather the following:
- Identity Proof: Aadhar, PAN, or any other ID proof
- Policy Document: Carry your policy number and card for cashless claims
- Doctor’s Prescription: This is required only for planned hospitalisation or if mentioned under the policy terms.
- Hospital Records: Admission slip, discharge summary, and all bills
Keeping these documents ready ensures the claims process remains smooth and avoids delays.
Step 5: Submitting Documents for Cashless Claims
For cashless claims, the TPA desk at the network hospital contacts the insurer directly. However, here’s what you need to ensure:
- Pre-Authorisation: The hospital sends the pre-authorisation form to the insurer. If all details are accurate, approval is generally quick.
- Documentation: Provide all original documents, such as doctor’s consultation letters, treatment records, lab reports, and prescriptions.
Step 6: Filing for Reimbursement Claims
If you choose a non-network hospital or your mediclaim insurance policy doesn’t offer cashless benefits, you must go for reimbursement. Here’s how:
Collect all Original Documents: After treatment, gather all documents, including:
- Discharge summary
- Detailed hospital bills with cost breakdown
- Original Paid Receipts: Ensure all bills are marked as paid and have official receipts.
- Lab and Test Reports: All test results related to the treatment.
- Doctor’s Consultation Records: The first consultation letter and any other prescriptions.
Fill the Reimbursement Claim Form: Obtain the form from your insurer’s website or branch. Fill it accurately to avoid delays.
Submit Within the Insurer’s Timeline: Submit all documents along with the filled claim form within the time limit specified in your policy, usually 15–30 days post-discharge.
Step 7: Waiting for Claim Approval
After submitting your claim documents, the insurer’s team reviews the claim to verify its validity. During this phase:
- Document Verification: The insurer may contact you for additional information or documents, so keep all papers handy.
- Approval or Rejection: Claims are approved when all necessary documents are in place, and the policy covers the treatment. If your claim is denied, the insurer should provide a reason, which can usually be challenged with additional supporting documents if required.
Step 8: Claim Payout for Reimbursement Claims
Once your reimbursement claim is approved, the insurer will transfer the agreed amount to your bank account. Depending on the insurer’s policies, this process may take a few days to weeks.
Pro Tip: Make sure your NEFT details (bank account number, branch name, and IFSC code) are accurately mentioned in the claim form for a swift payout
Conclusion
Filing a mediclaim insurance claim may seem complex, but following a structured approach can make it smooth and stress-free. Each step matters from intimation and document collection to claim submission and final settlement.
Being well-prepared and timely in your actions can ensure a swift and successful claim process. And remember, always renew health insurance policy on time to avoid lapses in coverage and stay protected against unexpected medical costs.
