Claim efficiency is all about how fast a customer need is served in the time of hardship.
Claim settlement is multilayered process. In India, how fast and efficiently a claim can be
settled is majorly dependant on modes of claim. Claims can either be made through cashless
facility or by reimbursement mode. Let’s see how claim time varies in both the cases:
If treatment was availed through network hospitals listed with your insurer, you generally don’t
have to pay anything to the hospital. Your insurer or their third party agents (TPA) will take
care of your bill and settle it with the hospital directly. Claim process varies based on whether
it is a planned treatment or emergency treatment.
In case of planned treatment,
you need to inform the insurer in advance atleast 4 days before in most of the cases. Request
for cashless claim needs to be placed by submitting a hardcopy or through customer care. Request
can even be placed online, which is more convenient. Upon reviewing your request, insurer will
send an authorization to network hospital with clear indication of coverage amount. Same will
also be communicated to you. You just have to produce your insurance card, identity proof and
copy of confirmation at the time of admission to hospital.
In case of emergency treatment,
cashless claim request will be placed through TPA by the network hospital where policyholder
is admitted. You need to inform your insurer within 24 hours of hospitalization. Your insurer
will provide confirmation letter to the network hospital with policy coverage after reviewing
the details of claim request. Medical bills will be settled by insurer and payment will be made
to hospital directly.
Most of the insurers have quick claim approval for cashless claims. For example, Apollo Munich
has a 1 hour claim approval system and Max Bupa assures a response to your claim request within
30 minute. Likewise, most of the insurers have their own turnaround time for your cashless claim
request. However, pre-authorization is not a final approval. Settlement amount may vary with the
progress of treatment as more things come in to light. Final stage of settling the claim after
submitting a discharge summary may take hours as documents undergo a detailed scrutiny at many
levels. Entire process of claim might get delayed due to end moment paperwork that may arise.
If treatment was availed at hospital out of cashless network, you have to get the medical bills
reimbursed from your insurer. In this case, you will have to submit the dully filled claim form
along with necessary documents and original medical bills to a third party agent or to your
insurer within stipulated time frame. Acceptance or rejection of your claim will be decided
based on evaluation of your claim documents. On acceptance, payout will be made to your bank
account based on the details furnished by you. Majority of claims get settled within 15-30 days
time. It may even take months in few cases.
Claim payout time is normally based on:
- Medical bill amount – bills with huge amount requires scrutiny of several levels
- Insurer’s efficiency in processing the claim
- Mode of claim request (electronic or hardcopy)-electronic mode saves time by providing information to insurer quickly.
- How rational is your claim and legibility of your form
- Accuracy of information
Basically, if everything goes right, your claim would get settled smoothly and faster, say
between 15-30 days time. Time limit may vary from insurer to insurer. As per IRDA, if the claim
is delayed by more than 30 days of submission of claim documents, then insurer need to pay the
interest on delayed payment. Hence, timely settlement of claim is good for both you and your
To conclude, cashless claim facility is the quick way to avail your health insurance claim.
But, it’s important to understand the process in advance as you can save yourself from
last-minute procedural hassles. Tracking and monitoring your claims online also helps you
avoid delayed payment. Choose the right insurer, keep your insurance documents handy, furnish
correct information, and be prompt to experience the smoother process and to get the claims