How Long Does It Take To Process A Health Insurance Claim?

One of the biggest aspects of buying health insurance is that one can raise a claim when necessary and receive financial compensation. Thus, it is important that one should have all the information about claims, including their types and the time it takes to process a claim. 

The different types of health insurance claims function like this – 

1. Indemnity claims: 

Indemnity covers most basic mediclaim plans. Indemnity-based health plans cover hospitalisation costs up to the sum insured. This insurance allows cashless and reimbursement claims. 

2. Cashless Claims:  

Health insurance companies immediately pay hospitals for cashless claims*. Only hospitals with which the insurance company has a cashless claim agreement can offer this service. Empanelled or network hospitals offer cashless claim services. 

3. Reimbursement claims:  

After paying for hospitalisation*, you can obtain reimbursement from the insurer. Network and non-network hospitals offer a refund. Your insurer must receive your hospital bills and other paperwork within a few days of discharge. 

Insurance firms set timelines for reimbursement. If a patient is proceeding with the planned medical treatment, the policyholder must inform about the medical treatment and the hospital details two days before the admission. 

If an emergency prevented you from notifying the insurer, do so immediately after hospitalisation. If the policyholder is admitted into a non-network hospital in an emergency, the insured must be informed within 24 hours. 

Note:

A look at the health insurance claim settlement ratio of the various companies can help you get a better idea of the chances of your claim getting approved. 

Hospitalisation reimbursement*: 

Most health plans cover pre- and post-hospitalisation* fees. The insurer must cover charges 30 days before hospitalisation and 60 days after release. However, cashless hospitalisation* may require a separate reimbursement health insurance claim status. The insurance company or TPA must receive medical bills relevant to the disease for which the insured was hospitalised.  

After verification, the insurer will reimburse pre- and post-hospitalisation costs within a specific timeframe. 

Check sub-limits: 

Many health plans have lower medical condition sub-limits. Thus, more than a more significant sum insured is needed. To avoid last-minute surprises, verify if your policy has a sub-limit for the medical condition that requires hospitalisation. 

Sub-limits diminish claim amounts. The policyholder can only claim the amount below a sub-limit for specific situations such as room rent, treatment for certain ailments, or post-hospitalisation payments. Network hospitals can maintain costs under this sub-limit, but problems or more extended stays may increase charges.  

Knowing the sub-limit helps reduce spending by ensuring appropriate room rent and treatment costs. You can utilise another policy to cover extra costs if you have numerous. 

Reimbursement payment time: 

Reimbursement claims take longer than cashless claims, which usually happen within hours. Hence, the process was swift. You need to file the reimbursement claim as the earliest. Policyholders must pay for all care at non-network hospitals. The insured can submit all essential documentation within 7-15 days after discharge. 

The insurance will take weeks to process your claim – 

However, answering claim department questions can take time. The insurance company or TPA (whichever option the policyholder takes) verifies paperwork, records, bills, diagnosis reports, etc., to complete the reimbursement claim in 21 days. The health insurance company/TPA contacts policyholders to clarify invoices and statements. If not, the claim will be settled within 21 working days. 

‘Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.‘ 

*All savings are provided by the insurer as per the IRDAI approved insurance plan. Standard T&C apply 

(* Standard T&C Apply )