Health Insurance Claim Process Explained Step by Step

Planned treatments and routine hospital visits require smooth coordination, and a clear understanding of the claims process helps avoid unnecessary hassle. Many policyholders simply look for clarity around documentation, timelines, and insurer requirements.

This blog breaks down the health insurance claim process step by step, from hospital admission to final settlement, helping you understand each stage, prepare the right documents, avoid common mistakes, and achieve smoother, faster claim approvals.

Understanding the Basics of Health Insurance Claims

A health insurance plan helps cover hospitalisation and treatment costs, but the benefits are realised only when claims are filed correctly. Health insurance claims are requests made to insurers to pay for covered medical expenses. These claims can be cashless or reimbursement-based, depending on the hospital network and policy terms.

Knowing the health insurance claim procedure in advance helps you avoid rejections and delays, especially during emergencies when quick decisions matter.

Types of Health Insurance Claims

Before starting the health insurance claim process, it is important to know which type applies to you.

Cashless Claims

Available only at network hospitals
The insurer directly pays the hospital
Minimal out-of-pocket expense
Faster medical claims processing

Reimbursement Claims

Used at non-network hospitals
You pay first and claim later
Settlement usually takes 3 to 4 weeks
Requires complete documentation

Both options fall under standard medical claim insurance coverage, but the steps and timelines differ slightly.

Step-by-Step Health Insurance Claim Process

Below is a clear breakdown of the medical insurance claims processing steps from admission to settlement.

Step 1: Inform the Insurer

Notify the insurer or TPA within:

48 hours for planned hospitalisation
24 hours for emergencies

Timely intimation is mandatory under every medical claim policy.

Step 2: Pre-Authorisation (For Cashless Claims)

The hospital submits a pre-authorisation form to the insurer. Approval depends on coverage limits and policy terms.

Step 3: Hospitalisation and Treatment

Once approved, treatment begins. Keep all prescriptions, reports, and bills safely.

Step 4: Discharge and Document Collection

At discharge, collect original bills, discharge summary, diagnostic reports, and receipts. These are essential for reimbursement claims.

Step 5: Claim Submission

Submit the filled claim form with documents to the insurer within the specified timeline. This completes the health insurance claim process.

Step 6: Verification and Settlement

The insurer verifies documents and policy validity. Approved claims are paid directly to the hospital or credited to your bank account as part of the health insurance claim settlement.

Documents Required for Claim Filing

Claim Type	Key Documents Required
Cashless Claim	Pre-authorisation form, health card, ID proof
Reimbursement Claim	Claim form, discharge summary, hospital bills, prescriptions, diagnostic reports, cancelled cheque

Factors That Affect Claim Approval

Policy coverage and exclusions
Waiting periods
Disclosure of medical history
Accuracy of submitted documents

This evaluation impacts the health insurance companies' claim settlement ratio, which reflects how efficiently insurers honour claims.

Why Claim Settlement Ratio Matters

The health insurance claim settlement ratio shows the percentage of claims settled by an insurer in a year. The medical insurance claim settlement ratio indicates reliability in paying valid claims.

Choosing insurers with a strong health insurance claim settlement ratio improves the chances of smooth approvals. Many experts recommend checking the insurance claim settlement ratio before finalising a policy.

A higher claim settlement ratio usually means:

Faster approvals
Fewer disputes
Transparent claim handling

Common Reasons for Claim Rejection

Even with valid coverage, claims may be rejected due to:

Non-disclosure of pre-existing conditions
Claims during waiting periods
Treatment exclusions
Lapsed policy status
Late submission of documents

Understanding these risks helps you follow the health insurance claim procedure correctly.

Expert Tips for Faster Claim Settlement

Prefer network hospitals whenever possible
Inform the insurer within deadlines
Double-check forms for accuracy
Maintain copies of all documents
Understand your medical claim policy limits

Following these tips simplifies medical claims processing and reduces stress during recovery.

Conclusion

A clear understanding of the health insurance claim process helps you focus on recovery instead of paperwork. From timely intimation to proper documentation, every step matters. While insurance covers medical costs, unexpected gaps can still arise. In such situations, Kissht’s instant personal loans can help manage urgent expenses smoothly, without disrupting your financial stability.