Filing a health insurance claim might seem confusing, especially when you’re already dealing with the stress of a hospital visit. But once you understand the process, it becomes pretty simple. Whether you're trying to get cashless treatment at a network hospital or need to get reimbursed for expenses you already paid, I’ll walk you through it all—step by step.
Understanding Health Insurance Claims
A health insurance claim is a formal request you send to your insurance company to pay for medical services you've received. You’re basically asking your insurer to cover your hospital bills, lab tests, surgery, or any eligible medical expenses based on your policy.
There are two main types of claims:
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Cashless claim – This is when the insurance company pays the hospital directly, so you don’t have to spend money upfront.
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Reimbursement claim – Here, you pay first, and then the insurer refunds you after reviewing your documents.
You’ll usually file a claim after hospitalization, surgery, or any major medical treatment. But it can also apply for daycare procedures or even diagnostic tests, depending on your plan.
Prerequisites Before Filing a Claim
Before you file any claim, there are a few things to get in order:
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Know your policy: Read your health insurance document carefully. Some treatments might not be covered, like cosmetic surgery or pre-existing diseases during the waiting period.
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Check the network hospitals: Cashless claims only work at hospitals partnered with your insurer.
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Keep your policy number and ID card ready. You'll need these at the hospital or while filling out the claim form.
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Pre-authorization: For cashless claims, some insurers ask for approval before treatment, especially for planned surgeries or procedures.
Filing a Cashless Claim – Step-by-Step
Cashless claims are the easiest because you don’t need to pay upfront (except for non-covered expenses like registration or food charges).
Here’s how it works:
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Choose a network hospital: Use your insurer's website or app to find hospitals that offer cashless facilities.
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Show your ID card at the hospital’s insurance desk.
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Fill out a pre-authorization form, which the hospital staff usually helps with.
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The hospital sends this form to your insurer or their TPA (Third Party Administrator).
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Once approved, the insurer directly pays the hospital after treatment.
If the claim is denied, don’t panic. You can still pay and later file for reimbursement.
Filing a Reimbursement Claim – Step-by-Step
Sometimes you go to a hospital that’s not in the network, or maybe the insurer rejects your cashless claim. In such cases, you pay first and get reimbursed later.
Here’s what you do:
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Collect all original bills and reports after discharge.
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Download the claim form from your insurance company’s website.
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Fill out the form carefully. Double-check bank details and patient information.
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Attach all required documents (see next section).
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Submit your claim either online, through email, via the mobile app, or send it by post.
The submission window is usually 7–30 days after discharge—don’t delay.
Essential Documents for Filing a Claim
You’ll need these papers for a reimbursement claim:
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Discharge summary
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Final hospital bill with detailed charges
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All prescriptions and medicine invoices
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Diagnostic reports (X-ray, MRI, blood test, etc.)
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Cancelled cheque or bank account details
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Insurance policy copy and ID proof
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Filled claim form
Always keep copies of everything you submit. It’s your backup.
Common Mistakes to Avoid
These errors often lead to claim rejection or delays:
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Incomplete claim form
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Submitting photocopies instead of originals (for reimbursement)
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Missing documents like lab reports or prescription slips
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Getting treated at a non-network hospital and expecting cashless
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Delaying the claim submission beyond the allowed time
Being a little organized can save you a lot of stress later.
Tracking and Following Up on Your Claim
After you submit your claim:
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Use the claim reference number to track the status online or via the app.
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If your claim is delayed beyond 15-20 working days, call the customer care or your TPA.
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Insurers are supposed to give updates at each step—approval, query, or rejection.
If you're stuck, escalate the issue through the insurer’s grievance redressal channel.
What to Do If Your Claim Is Denied
Claims can be denied for many reasons:
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Treatment not covered under your plan
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Pre-existing disease during waiting period
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Lack of supporting documents
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Policy lapsed or inactive
If your claim gets rejected:
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Ask for the exact reason in writing.
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Submit additional documents if requested.
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File an appeal with the insurer.
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If needed, escalate the issue to the IRDAI or approach the insurance ombudsman.
You have the right to get a fair review.
Tips for a Smooth Claim Process
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Always carry your health insurance card.
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Inform the insurer immediately during hospitalization—some require notice within 24 hours.
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Keep all medical bills, prescriptions, and reports safe and sorted.
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Use your insurer’s mobile app—most now allow claim tracking and paperless submission.
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Take photos or scans of all original documents before handing them over.
A little preparation goes a long way.
FAQs
Can I file a claim online?
Yes. Most insurers let you upload documents and track claims digitally.
How long does reimbursement take?
Usually 7 to 21 working days, depending on your insurer and documentation.
Can I file multiple claims in a year?
Yes, until you exhaust your sum insured limit.
What if I lose my medical bills?
Try to get duplicates from the hospital. Claims without original bills may get rejected.
Conclusion
Filing a health insurance claim doesn't have to be overwhelming. Once you know what documents to collect and which steps to follow, the process becomes smooth and predictable. The most important thing? Read your policy carefully, stay organized, and act fast. Whether you're aiming for a cashless claim or getting a reimbursement, doing it right means you’ll get your money back without the headache.
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