What Is the Process to Claim In Health Insurance

Health Insurance is a good investment to protect yourself and your family from the high cost of medical treatment. But when it comes to filing a claim, many people feel that the process is difficult.

What Is the Process to Claim in Health Insurance
What Is the Process to Claim in Health Insurance

However, the process of claiming health insurance is not complex as it may seem. In this article, we will take a look at the steps involved in the process of filing a claim for health insurance.

What is a Health Insurance Claim?

A health insurance claim is a request made by a policyholder to their insurer to cover the expenses incurred for medical treatment. The claim is submitted to the insurance provider after the policyholder has received medical care from a healthcare provider or hospital. The insurance provider reviews the claim and decides whether to pay for the medical expenses or not.

Making a claim on health insurance is typically simple, but it can vary depending on the type of policy and the insurance company. The policyholder must give the insurance company all required information, including the details of the medical care received, the name of the doctor or hospital, and the total amount of the medical expenses, in order to submit a claim.

Types of Health Insurance Policy Claims

While purchasing a health insurance policy, it is crucial to understand the different types of claims that can be made. Let’s take a look at the different types of health insurance claims

Cashless Claims

In a cashless claim, the insurance company settles the medical bills directly with the hospital or healthcare provider. In this type of claim, the policyholder does not have to pay for the medical expenses out of pocket.

To benefit from the cashless claim, the policyholder needs to be admitted to a hospital that is on the insurance company’s network. Once the policyholder is admitted, they will provide their insurance details to the company and the hospital will contact the insurance company directly to get the claim settled.

Reimbursement Claims

In this type of claim, the policyholder has to pay for the medical expenses out of pocket. Later, they can apply for reimbursement from the insurance company. The policyholder needs to keep all the medical bills and other documents that are necessary for the claim. The policyholder needs to submit these documents to the insurance company along with the claim form/. Once the insurance company verifies the documents, the claim will be settled.

Pre-Hospitalization Claims

This type of health insurance claim covers the medical expenses incurred by the policyholder before getting admitted to the hospital. This expense includes diagnostic tests, consultations, and medications. The policyholder needs to provide all the relevant documents to the insurance company in other to avail of this claim.

Post-Hospitalization Claims

Medical costs incurred by the policyholder following hospital discharge are covered by post-hospitalization claims. The costs may cover prescriptions, diagnostic exams, and follow-up consultations. To submit this claim, the policyholder must give the insurance company all necessary documentation.

Day Care Procedure Claims

Medical costs incurred by the policyholder for procedures that don’t involve a more than 24-hour hospital stay are covered by daycare procedure claims. Dialysis, chemotherapy, and cataract surgery are a few examples of these procedures. To submit this claim, the policyholder must give the insurance company all necessary documentation.

Requirements to File an Insurance Claim

When a policyholder receives medical treatment, they can file a claim with their insurance provider to receive reimbursement for their expenses. However, to file a successful health insurance claim, certain requirements must be met. In this part of this article, we will discuss the requirements to file a health insurance claim.

Active Health Insurance Policy

The first requirement for filing a health insurance claim is that the individual must have an active health insurance policy. This policy must be current and up to date and the individual must have paid all premiums due. Without an active health insurance policy, the individual cannot file a claim.

Accurate Information

When filing a health insurance claim, it is very important to provide accurate information. The information must be true and correct. Providing false information can result in the claim being denied or it can even lead to the cancellation of the policy.

Proper Documentation

Proper documentation is very essential when filing a health insurance claim. This includes all medical records, bills, and receipts related to the treatment received. This will help the insurance company review your documentation to determine the validity of the claim. If the documentation is incomplete or inaccurate, the claim will be denied.

Timely Filling

Health Insurance claims must be filed within a certain timeframe. The timeframe varies depending on the insurance company and the type of policy. Generally, claims must be filed within a specific number of days after the medical treatment is received. Filing the claim late can result in the claim being denied.

Medical Necessity

The medical service or treatment must be both medically necessary and covered by the insurance plan. This means that both the policy and the treatment must be covered and the treatment must be necessary to maintain the person’s health and well-being. The claim will be rejected if the procedure is not medically required or is not covered by the insurance.

Following the Claims Process

Each insurance company has a specific claims process that must be followed. This process typically involves filling out a claim form and submitting it along with the required documentation. It is essential to follow the claims process to ensure the claim is processed correctly.

By meeting this requirement, individuals can increase their chances of a successful claim.

Health Insurance Claim Process

Understand your Policy

Before you start the process of filing a claim, it is very important to understand your health insurance policy. Make sure you read the policy carefully and also understand the coverage, terms and conditions, and exclusions. Check if the medical treatment you are seeking is covered by your policy.

Seek Medical Treatment

Once you have reviewed your policy, you can visit a hospital or clinic in affiliation with your insurer or any other hospital or clinic that you prefer. Make sure you have all the necessary documents such as the medical bills, diagnostic reports, and other details.

Inform your Insurer

Once you have received medical treatment, inform your insurer about the treatment and the amount of the claim. You can call the customer service of your insurer or by filling out the claim form online. Provide your insurer with some necessary details such as your policy number, date of treatment, and the amount of the claim.

Submit the Documents

After you have informed your insurer, you may be asked to submit some required documents. These documents may vary depending on the insurer, but generally, you need to submit the claim form, medical bills, diagnostic reports, and discharge summary. Make sure you submit the required documents in time to avoid any delay in the claim process.

Wait for Approval

After submitting the documents, the insurer will verify the claim and assess the eligibility of claim. You may be asked to submit other documents or information. Once the claim is approved, the insurer will reimburse the amount of the claim to you or the hospital.

What to Do When Your Health Insurance Claim Is Denied

Sometimes, health insurance claims can be denied, which can be frustrating and stressful for policyholders. If you find yourself in this situation, there are several steps you can follow to resolve the issue and potentially receive the coverage you deserve.

Understand Why Your Claim was Denied

The first step in appealing a denied health insurance claim is to understand why it was denied. There are many reasons why a claim might be denied, including; the claim being filed after the deadline, the service is deemed not medically necessary or the treatment was not covered by your insurance plan. Understanding the reason for the denial will help you determine the right course of action.

Review Your Insurance Policy

It is very important to review your policy carefully, to ensure that the denied claim is not a result of a misunderstanding of the policy. Review the policy and check if the services you received are covered by your insurance plan. If you find any issues, contact your insurance provider for clarification.

Appeal the Decision

If you believe your claim was denied in error, you have the right to appeal the decision. The appeal process varies by insurance provider. So, check with your insurance company for specific instructions on how to appeal. Make sure you follow the appeal process carefully and provide all necessary information when needed.

Seek Assistance

If you have any difficulty navigating the appeal process, you can seek assistance from a healthcare advocate or an attorney specializing in healthcare. These professionals can help you understand your rights, review your policy and also advocate on your behalf with your insurance provider.

Consider Filing a Complaint

If your insurance provider does not respond to your appeal, you can proceed to file a complaint with your state insurance department. The department will investigate your complaint and work with your insurance provider to resolve any issues.


The process of filing a health insurance claim is straightforward and it can be completed without difficulty. It’s important to understand your policy, get medical attention, notify your insurer, provide the necessary documentation, and wait for approval. You can guarantee a simple and stress-free claim process by following these steps.

Frequently Asked Questions

What is Pre-authorization and why is it Necessary?

Pre-authorization is a process in which the insurance company approves a medical procedure or treatment before it is performed. This is typically done to ensure that the treatment is medically necessary and to confirm that it is covered under the policy.

Can I Change My Health Insurance Policy after I File a Claim?

Once you have filed a claim, you may not be able to change your policy until the claim has been resolved. It is very important to review your policy carefully before filing a claim to ensure that you have the coverage you need.

Can I Choose my Healthcare Provider for my Health Insurance Claim?

The coverage of healthcare providers varies depending on the insurance policy. Some policies may allow you to choose any provider, while others require you to use providers that are in-network. You should consider checking your policy before choosing a healthcare provider to ensure that they are covered by your insurance.



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