Insurance Query: When filing a health insurance claim

What are some best practices to follow when filing a health insurance claim in India?

The health insurance claim process becomes far more seamless when policyholders understand their coverage in advance. Many only turn to the fine-print at the time of hospitalisation, when there is little time to spare. Given the range of inclusions, exclusions and conditions that can affect a claim, knowing your policy well is critical to a smooth claims experience.

There are two ways to file a claim: cashless and reimbursement. Under a cashless claim, the insurer settles eligible medical expenses directly with the network hospital. However, policyholders may still have to pay for non-covered items, co-payments, deductibles or expenses exceeding policy limits.

Under reimbursement, you pay the hospital first and claim the eligible amount from the insurer later. This route typically applies when you are treated at a non-network hospital or are unable to obtain cashless pre-authorisation.

Where possible, opt for cashless treatment and identify your nearest network hospitals in advance. These two steps can save significant time and stress during an emergency.

Some policies require policyholders to bear a fixed percentage of every admissible claim, known as co-payment. For instance, with a 20 per cent co-pay and an admissible claim of ₹1 lakh, you would pay ₹20,000 while the insurer pays ₹80,000.

Co-payment clauses are common in senior-citizen plans and certain policy variants. They can significantly increase out-of-pocket expenses during hospitalisation, so check the clause before buying or renewing a policy.

For cashless claims, share the medical records, proposed treatment and estimated costs with the insurer ahead of the procedure, wherever possible. If the approved amount is lower than the final hospital bill, you may have to pay the difference and seek reimbursement separately.

Review the pre-authorisation approval carefully before discharge so you are clear about what the insurer will and will not cover.

Keep prescriptions, consultation notes, diagnostic reports and bills organised from the start of treatment. This is particularly important for reimbursement claims, where incomplete documentation can lead to delays and repeated correspondence with the insurer.

Many claim-related disputes stem from policyholders being unaware of their policy’s limitations. Review room-rent limits, waiting periods, disease-specific caps and exclusions before you need to make a claim.

Room-rent limits, in particular, can catch policyholders off guard. If you choose a room above the eligible category, the insurer may proportionately reduce its contribution towards several associated hospital expenses, potentially increasing your out-of-pocket cost significantly.