Health Insurance: How to ensure your claim doesn't get delayed or rejected? Experts explain

It's bad enough that you have been incapacitated with some disease or loss that has caused you to lose time and money; what is probably as bad is the paperwork that is inevitable, the processes that must be followed to get your insurance claim processed.

From checking the hospital, to intimating your insurance company about your illness to the way that you may get some leeway, experts guide how you should dot the I’s and cross the T’s.

“Typical mistakes in insurance claims include providing inaccurate information, missing required documents, and not adhering to claim submission deadlines,” says Rakesh Goyal, Director, Probus Insurance.

“Taking treatment in one of the restricted or blacklisted hospitals as decided by the insurance company,” says Siddharth Singhal, Business Head - Health Insurance, Policybazaar.com. Customers need to check for such a list of blacklisted hospitals in their area before filing a claim.

To file a claim, most insurers mandate a minimum of 24 hours of hospitalisation. Hence making a claim for a condition that does not require hospitalisation for at least 24 hours may not be covered.

In case of multiple policies held by a customer, the customer must clearly indicate in the claims form - the policy number on which they want to file the claim.

“Insurance companies have a standard requirement template when it comes to claims,” says Rakesh Jain, CEO, Reliance General Insurance, explaining the process from the insurance company’s point of view.

The claimant must submit a correctly filled claim form and submit documents like diagnosis reports, treatment bills, doctor’s consultations, etc., in case of a hospitalisation claim.

This is a relatively simple process; however, most people tend to make common mistakes at this stage, like filing incomplete or incorrect claim forms or being negligent in submitting the right set of documents, which leads to delays in the claim settlement procedure.

Claimants also should be aware of their policy inclusions & exclusions to reduce confusion related to coverage at the time of claim.

An important point is the timeline that you have during which you must inform the company and file your claim. After all you have to inform the insurance company within 24 hours of any emergency or unplanned hospitalisation. Consider that you may have had an accident and you are probably in a hospital – what then?

“In such a scenario, the insured member or any family member or any friend can inform the insurance company within 24 hours of unplanned hospitalisation,” notes Singhal. This intimation can be simply via the claims desk present at every hospital or directly to the claims helpline of the insurance company.

“Yes, insurance companies indeed approach health claims in a very sensitive manner considering the condition of the claimant,” says Raghavendra Rao, Chief Distribution Officer, Future Generali India Insurance Company. To that extent - relaxations on submission timelines of claims, registering and submission of claims via digital modes, assisting customers via various touch-points are few of the initiatives that insurance companies take.

“Insurance companies often consider the claimant's health or mental state, making reasonable allowances and assistance to ensure a smooth claims process during challenging times,” notes Goyal.

But still we wonder suppose there is no relative or friend to help you with your claim, or you are in some different country, what then? “In a rare instance where none of the persons is able to inform the insurance company due to an unavoidable reason, the insurance company may admit the claim basis the merit,” says Singhal.

The insurers typically give time of 30 days to submit a reimbursement claim from the date of discharge. For a cashless claim, it is desired that intimation comes to the insurer within 24 hours of admission in emergency cases and 24-48 hours before a planned admission. “The insurers apply a flexible approach on these timelines and do honour claims which are beyond these,” says Rao.

In case of planned treatment, customers can intimate the insurance company 48-72 hours in advance to get the pre-authorisation on their claim. This generally is received within 2-3 hours of claim intimation.

In the case of a cashless claim, it takes an average of 1-2 hours for the initial approval to come. However, if further investigation is required on the reason for hospitalisation, the approval may take up to 24 hours.

In case the customer files for a reimbursement claim, the insurance company usually gives the decision within 7-8 days after the customer submits all required documents.

According to the Insurance Regulatory and Development Authority of India (IRDAI) guidelines, an insurer has to settle a claim within 30 days from the date of receipt of the last necessary document.

But do note there are some circumstances where your insurance company pay you a visit for the verification of your claim.

“If there is suspicion or doubt about the authenticity or validity of the claim,” says Jain about why your insurance company may pay you a visit for checking.

Misrepresentation or discrepancy in the information provided by the claimant or the hospital and if there is a request or complaint from the claimant are some of the other circumstances for a ground level visit.

In case of a visit from the insurance company, claimants should have relevant information such as original bills and receipts, discharge summaries, medical reports and tests, prescriptions, medicines, and identity proof to support their claim.

Rao notes that there is an increase in fraud across the industry, so insurers have developed mechanisms and tools to identify such cases. Whenever there is a manipulation in documents, bills, treatment course or pattern seen from a particular customer / set of customers, the insurers can choose to apply extra due diligence and verify the facts.

A customer need not have extra paperwork with him, as he would have submitted all relevant documents to the insurer already. However it is always handy to keep any further document related to the admission that the claim is made for.

The policyholder can approach the Grievance Redressal forum of the insurance company and if still not satisfied, can reach out to the IRDA via the following ways:

Redressal of complaints

● Can make use of the Bima Bharosa system - IRDAI portal at https://bimabharosa.irdai.gov.in/ for registering the complaints themselves and monitoring the status of the complaints.

● Can send the complaint through email to complaints@irdai.gov.in.

● Can call Toll Free No. 155255 or 1800 4254 732.

● Apart from the above options, if it is felt necessary by the complainant to send the communication in physical form, the same may be sent to IRDAI.