Faq - Health Insurance Claims

You receive a No Claim Bonus (NCB) as a rewarding perk in your health insurance policy. It is the insurer’s way of acknowledging a year without claims. This bonus boosts your coverage at no additional premium.

Yes, it is important to let the insurer know about your health in as much detail as possible. If you do not inform, then it may lead to the insurer rejecting your payment request (claim) at the time of need.

Domiciliary hospitalization is when the patient is being treated in his/her hometown. This may happen because the patient is immobile and cannot be moved due to the high risk involved or on the instruction from the hospital. Costs incurred for such treatments are also covered in most health insurance policies.

Yes, you can. However, you need to disclose the other policies to the existing insurers. In case of a claim, you can decide which insurer you would like to approach. For example, if a customer has two policies of Rs 1 Lakh each from insurers A and B, and there is a claim for Rs 1 Lakh, then you can choose to use up Rs 1 Lakh from only insurer A or B or opt to claim Rs 50,000 under both insurers A and B.

Pre- hospitalization costs include expenses like OPD visits, ambulance cover, blood tests etc. that take place before you get admitted for your treatment whereas post-hospitalization expenses include physiotherapy, follow-up doctor visits or medications prescribed after your treatment is over and you have been discharged from the hospital. Pre-hospitalization cover of 30 days implies any costs incurred 30 days before the hospitalization will be covered. This cover normally ranges from 30-90 days.

Under Section 80 D of the Income Tax Act 1961, a tax deduction can be claimed for the premium paid for your health insurance.

The premium paid is eligible for deduction from your income (gross) thereby reducing your tax liability

To know further details about Income Tax deductions, please check with your Tax consultant

Customer needs to contact TPA desk at network hospital to give a copy of his/her Health Insurance ID card and Identity proof at Hospital reception. Pre-authorisation form has to be filled which has two parts. Part 1 needs to be filled by the patient or the patient’s family and part 2 needs to the filled by the Hospital authority/Treating doctor.

The completely filled form should be faxed or mailed to Health Insurance TPA/ Insurance company. Once pre-authorisation form is received the case will be processed and the initial authorization letter (approved or rejected) will be faxed/emailed back to hospital by Health Insurance TPA/Insurance company.

Note:- For planned hospitalization: - Pre-authorisation form to be sent before 48 hours of hospitalization. For Emergency: - Pre-authorisation form to be sent within 6 hours from the time of admission.

1. Patient discharge summary/card issued by the hospital
2. Hospitalization bills
3. Doctor’s prescriptions/consultation receipts
4. Pharmacy invoices
5. Claim forms self-attested by the concerned policyholder
6. Valid investigation report issued by the hospital or treatment facility
7. Bills for consumable items as prescribed by the doctor, required for the treatment
8. Copy of the health insurance card and the health insurance policy document
9. In case of an accident, a copy of the FIR or any other Medico-Legal Certificate (MLC)
10. A cancelled cheque and other bank details of the bank account in which you wish to receive the reimbursement
11. Any other relevant documents as requested by the TPA/insurer 

Third Party Administrator (TPA) is service provider to all insurance companies servicing health Insurance policies. TPA adds value and facilitates smooth operation of health insurance policies through its value-addition like network of healthcare service providers, medical care standardization, Claims management, Client servicing, expert opinion etc.

In the event of hospitalization, the patient or their family will have a bill to pay the hospital. Under Cashless Hospitalization the patient does not settle the hospitalization expenses at the time of discharge from hospital. The settlement is done directly by Health Insurance company. This is to reduce the financial burden on insured individual at the time of hospitalization. 

There is no limit on the number of claims during the policy period. You can claim till your sum insured gets exhausted. For example, if your health cover is Rs 5 Lakh, you can make one single claim of Rs 5 Lakh or 5 claims of Rs 1 Lakh each, but the total claim amount cannot exceed Rs 5 Lakh. 

In such cases, for cashless treatments, the claim amount is settled directly with the network hospital. For reimbursements, the claim amount is paid to the nominee of the policyholder.

Non Medical expenses are: Admission fees, Registration fees, gloves, blade, water bed, food & beverages, extra bed etc.,

You might have to pay for non-medical expenses like service charges, admission charges, eatables for the attendants etc.  If there is a co-payment or deductible clause in the insurance policy, then you will be required to pay for that too.

Here is how the reimbursement claim process works:

• You get admitted at any hospital of your choice for treatment
• You inform the same to the Benefits Circle team via call/email four days before the procedure at the hospital for planned procedures and immediately on admission, for emergency cases
• The hospital provides you with the treatment. Post-treatment, you clear all bills at the hospital and submit the required documents to Benefits Circle
• Benefits Circle scrutinizes the documents and submits them to the insurer for claim processing. Benefits Circle also follows up with the insurer for the claim processing on your behalf
• The approved claim is transferred to you through NEFT

Rejection can be as per the policy terms and coverage, below are the few reasons:

1. If hospitalization is for observation & investigation purpose
2. If any particular aliment/disease/treatment is found not covered under policy term and condition
3. If found that the treatment can be done under OPD basis
4. If found that no active line of treatment is available
5. If Shortfall and the policy holder has not responded within the given TAT
6. If policy is invalid
7. Rejection of cashless is not a denial of treatment

Health Insurance covers all diagnostic test like X- ray, MRI, blood tests etc as long they are associated with the patients stay in the hospital for at least 24 hours. Any diagnostic tests which does not lead to treatment or which have been prescribed as Outpatient are generally not covered.

The minimum period of hospitalization required for a claim is 24 hours. However, in case of day-care procedures less than 24 hours claims are also approved depending on your policy terms.

Day Care surgeries are those which do not require 24 hours of hospitalization such as Cataract (Eye) surgery, Dialysis, Kidney stone removal, Chemotherapy, D&C etc.

Depending on Insurance policy some of the day care surgeries are payable according to term and conditions.

A health card is a card that comes along with the Health Policy. It is similar to an Identity card. This card would entitle you to avail cashless hospitalization facility at any of our network hospitals. A health card mentions the contact details and the contact numbers of the TPA.

In case of a medical emergency, you can call on these numbers for queries, clarifications and for seeking any kind of assistance. Moreover, you need to display your health card at the time of admission into the hospital.

You can change the hospital while keeping the insurer and/or us informed. If it is a cashless claim, you shall be required to fill out a claim request form again. We can assist you in such scenarios by getting in touch with the insurer and making the process smoother for you.

Some policies include international treatment and the same is mentioned in the policy document. However, many do not. In the latter case, only if the treatment has been done within India, will you be eligible for a reimbursement.

It will but after some years of you having the policy continuously. Any health insurance policy does not cover the existing disease from day one; the policy comes with a waiting period of typically two to four years.  However, the waiting period differs from one policy to another.

Claim intimation is the process of informing the insurer about your upcoming treatment and claim submission. You can also achieve this by calling our customer service number and informing us or writing to us.

Typically, a health insurance policy will provide cover across India.

There can be 2 scenarios here:

1. If you were hospitalized while the policy was still valid (NOT during the grace period), and if you have completed all formalities like informing the insurance provider and submitting required documentation, then the claim will be settled.
2. If hospitalization happens within the grace period, the insurance provider is most likely to reject the claim. But exceptions can always be made; hence, you must inform the insurer and ask for options.

Co-payment is a clause that requires you to share the medical expense with the insurer. It is a cost-sharing arrangement agreed upon by you at the time of buying a health insurance policy. For example, if the co-payment fixed percentage is 10%, then for a medical expense of Rs 1 Lakh, you will be required to pay Rs 10,000, and the insurer will bear the rest. You should go through all similar clauses in the policy before buying it.