What is a Health Insurance Claim?

What is a health insurance claim? How does a health insurance claim work? Health insurance is what a doctor submits to your insurance so they can get paid. It shows the medical service that was provided to you.

What is a Health Insurance Claim?

Submitting a claim, yourself depends on the kind of insurance claim plan you are operating with. Typically, your doctor or provider, especially if they are in your plan, will submit the claim for you.

What is a Health Insurance Claim?

A health insurance claim is a request made for direct payment or compensation for medical service that an insured person has gotten from medical personnel. Health Insurance benefits or reimbursement are obtained when an insured person submits a claim to their insurer or insurance provider.

Notwithstanding, before making a claim, you need to know the procedure for filing it and the document and information required to file a health insurance claim. Not to worry, in this article, we will be giving you a detailed explanation of how to file a health insurance claim.

How does Health Insurance Claim Work?

When it comes to health insurance claims, the process is kind of similar to others but very different. In this situation, your doctor’s office will submit a claim and you, on the other hand, will need to be involved in the process.

Your doctor will send a bill to your insurance company for any charge you did not pay during a visit or submit a claim for the service they provided to you during your visit. However, when that is done, your insurance provider will review the claim. They check for accuracy, and completeness and ensure there is no fraudulent activity that is with the action.

Types of Health Insurance Claim

There are two types of health insurance claims some of them include, Cashless claims and Reimbursement claims. As an insured person you can consider picking either of these two.

Cashless Claims

Under this type of health insurance claim, the insurer settles all the medical expenses with the hospital directly. However, to avail of the cashless mode of claim settlement, the policy beneficiaries need to be hospitalized at a network hospital.

The insurance company in this situation will take direct responsibility for all the bills involved in the insured treatment. Hence, all payment is made directly to the hospital account.

Reimbursement claims

With this type of health insurance claim, you can pay the hospitalization bill first and then for the reimbursement of the expenses. The insurance provider will pay the amount to the insured as per the term and conditions of the policy.

What is the Document Needed for Health Insurance Claim?

it does necessary matter if you are filing a cashless or a reimbursement claim on your health insurance policy, there are certain important documents that are required to be submitted. These includes

  • A copy of your first information report filed with the police (only needed when it is an accident case).
  • Your health insurance identity card.
  • Duly filed health insurance claim form.
  • A copy of your prescription and pharmacy bills.
  • Document detailing doctors’ consultation.
  • Lastly, your medical bills and reposts including hospital admission and discharge slips (applicable when you are hospitalized).

These and many more are documents that are needed for filing a health insurance claim.

How to File a Health Insurance Claim

Before you file an insurance claim, you should be aware of the type of health insurance plan you have set up. If it’s a cashless claim, your doctor would be responsible for filing the claim on your behalf.

However, you should provide all necessary documents given to the doctor. And when it is reimbursement claims, you have to go to the hospital yourself with the necessary documentation.

What Happens if your Health Insurance Company Declines to Pay a Claim?

if you feel your claim was wrongly denied, you have the right to appeal the decision, but the process can be confusing but not impossible. Two key considerations make a difference in the claim and appeal process:

  • Have you already received the care, service, device or prescription?
  • Is the care urgent?

When you figure out answers to this question, then you will be guided on the next step to take.



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