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A health insurance plan can be claimed if the policyholder is admitted to the hospital for at least 24 hours or, unfortunately, passes away in the hospital after 24 hours of admission. You can even make a health insurance claim if the policyholder dies due to an accident or medical illness. You can claim health insurance either through the cashless or reimbursement mode. The health insurance claim limit ranges from ₹ 1 lakh to ₹5 lakh.
Additionally, you can claim a health insurance policy after the initial waiting period of 30 to 90 days, depending on the policy type. For emergencies, including accidents, claims are allowed immediately. Claims can be made via cashless or reimbursement modes, with proper documentation helping avoid delays or rejection.
Key Takeaways
Health insurance claims can only be made after specific waiting periods, ranging from 30 days to 4 years, depending on the policy.
You can claim health insurance through cashless (direct insurer payment) or reimbursement (pay first, claim later).
Submitting complete and accurate documents ensures smooth claim approval and avoids unnecessary delays or rejections.
Understanding exclusions, coverage limits, and pre-approval requirements prevents claim rejection and financial surprises.
If your claim is denied, reviewing the policy, rectifying errors, and filing an appeal can help get it approved.
After How Many Days Can we Claim Health Insurance?
The initial waiting period is generally 30 days (minimum) to 90 days, and it can vary according to the policy. However, an exception can be made if the insured meets with an accident and needs emergency hospitalisation.
While in a disease-specific plan, the claiming period of coverage for a specific disease is a minimum of 1-2 years at all stages (early or advanced). The claiming period ranges from 1-4 years, with continuous policy coverage in the pre-existing waiting period.
The duration for such a waiting period depends on the medical condition and the chosen insurer. The next type is maternity plans, in which the waiting period ranges from 9-36 months. However, most of them offer a 2-4 year waiting period, and it is always suggested to the customers to purchase the policy early.
Pre-Inform before you are admitted for planned hospitaliSation. In case of emergency hospitaliSation, inform your insurance company within 24 hrs.
Provide hospital documents, including receipts, prescriptions, discharge papers, bills and copies of the report to the insurer while submitting the claim
While filling out the form to claim health insurance read all the guidelines carefully and follow the procedure accordingly.
Verify all insurance documents to ensure that the bank details are accurately completed
Submit the form and required documents at the earliest to avoid any delay.
It takes up to 45 days at the most to be completed. Until then, keep all the necessary documents prepared for additional requirements.
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What are the Types of Waiting Periods in Health Insurance?
When buying a health insurance plan, you may have come across the term 'waiting period', in the fine print. Well, many might overlook this, but a clear understanding of waiting periods is essential. It refers to the duration during which you cannot file a health insurance claim except for emergencies. Being aware of them ensures better financial planning and reduces the risk of claim rejection.
Below are mentioned the primary types of waiting periods applicable in health insurance policies:
Initial Waiting Period: The waiting period that applies immediately after purchasing a health insurance policy, typically ranging from 30 to 90 days, is referred to as the initial one. During this period, claims are not accepted except in cases of accidental hospitalisation
The purpose of this waiting period is to prevent fraudulent claims and ensure that only genuine policyholders receive the coverage benefits. Moreover, it encourages individuals to purchase health insurance early to avoid gaps in coverage.
Pre-Existing Disease (PED) Waiting Period: This waiting period applies to individuals with pre-existing conditions such as diabetes, hypertension, or asthma. The duration varies between 1 to 4 years, depending on the insurer and policy terms.
Some insurers offer the option to reduce this waiting period by paying an additional premium. It promotes enhanced financial planning for long-term healthcare needs and helps manage medical expenses effectively.
Specific Disease Waiting Period: Certain ailments, including hernia, cataracts, kidney stones, and joint replacements, are subject to a waiting period, typically lasting 1 to 2 years. This restriction varies across insurers and policy types. This waiting period promotes planned medical treatments accordingly. It also helps in selecting policies with shorter waiting periods for specific ailments.
Maternity Waiting Period:Health insurance policies that cover maternity expenses typically have a waiting period ranging from 9 months to 4 years. This applies to expenses related to pregnancy, childbirth, and the care of newborns. Encourages early policy purchase for maternity benefits. Reduces the financial burden associated with childbirth and related medical expenses.
Critical Illness Waiting Period: Policies covering critical illnesses such as cancer, stroke, and heart disease typically have a waiting period of 90 to 180 days. This is intended to help you have sufficient time to understand the eligibility requirements for claim benefits. Besides, it also helps in choosing the right health insurance plan based on individual medical risks.
Did You Know?
Health insurance also offers tax-exempt benefits under Section 80D of the Income Tax Act.
Source: ClearTax
How to Make Health Insurance Claims?
Knowing when to claim health insurance is crucial to ensure the process proceeds smoothly and is settled correctly. There are two ways to make claims: cashless or reimbursement.
Below is a step-by-step guide for both methods:
Cashless Health Insurance Claim (For Network Hospitals):
A cashless claim allows you to receive treatment without paying upfront, as the insurer settles the bill directly with the hospital. The following are the steps that you may follow to apply for cashless claims:
Step 1: Inform the insurer about planned hospitalisation at least 48–72 hours in advance. For emergency hospitalisation, notify the insurer within 24 hours.
Step 2: Present your health insurance card and policy details at the hospital’s insurance desk.
Step 3: The hospital will submit a pre-authorisation request to the insurer for approval.
Step 4: Once approved, the insurer covers eligible medical expenses directly. The policyholder only needs to pay for exclusions (if any).
Step 5: Collect discharge summaries, medical reports, and bills for your records.
Reimbursement for Health Insurance Claims (For Non-Network Hospitals):
If you receive treatment at a non-network hospital, you must pay the bills initially and request reimbursement later.
Step 1: Inform the insurer about the hospitalisation within the specified time frame.
Step 2: Pay the hospital bills and collect all relevant documents, including invoices, prescriptions, and reports.
Step 3: Fill out the claim form and submit it along with the required documents to the insurer.
Step 4: The insurer will assess the claim, verify the documents, and process the reimbursement within the policy’s turnaround time.
What are the Documents Required for Filing a Health Insurance Claim?
When filing a health insurance claim, you must make a note of the fact that all required documents are shared within the stipulated time and correctly. It is one of the most important things that help ensure a speedy and smooth approval process. You must also remember to check with your insurer for any additional document requirements to avoid delays.
The following documents are generally required when filing a claim:
Documents Required
Cashless Claims
Reimbursement Claims
Health insurance policy details or e-card
Required
Not required
Pre-authorisation form (filled by the hospital)
Required
Not required
Doctor’s prescription and treatment summary
Required
Required
Diagnostic test reports (if applicable)
Required
Required
Hospital bills and invoices
Required
Required
Discharge summary
Required
Required
Duly filled and signed claim form
Not required
Required
Hospital discharge summary and treatment papers
Not required
Required
Doctor’s consultation notes and medical history reports
Not required
Required
Pharmacy bills with prescriptions
Not required
Required
Original hospital bills and payment receipts
Not required
Required
Diagnostic test reports and investigation papers
Not required
Required
Cancelled cheque for direct reimbursement
Not required
Required
What Happens if Your Health Plan Claim is Rejected?
A health insurance claim may be rejected for several reasons, including incomplete documentation, policy exclusions, or errors in claim filing. In case your health insurance claim gets rejected, you can take the following steps:
Understand the Reason for Rejection: To understand why your claim was rejected, carefully examine the rejection letter. After that, you must compare the stated reason with your policy's terms to determine whether coverage is applicable.
Rectify Documentation Errors: If the claim was rejected due to missing documents or incorrect details, submit the necessary corrections to the insurer.
File an Appeal: If you believe the rejection is unjustified, you can submit a formal appeal with supporting documents. Provide any additional medical reports or prescriptions to strengthen your case.
Review Policy Terms: To avoid rejections, it is essential to regularly review your policy terms. This also helps ensure that your documents are submitted in a timely mannerand gives you time to seek clarification from your insurer in case of doubts.
Conclusion
Understanding when to claim health insurance benefits is important since it makes handling medical emergencies financially stress-free. Regardless of the claim type you opt for, knowing the required documents, potential rejection reasons, and waiting periods, streamlines the process further.
Remember, your policy’s fine print is the key to leveraging its benefits as and when needed without any hassle.
Glossary
Waiting Period: The duration you must wait after policy purchase before making a health insurance claim, except for emergencies.
Pre-existing Disease: A medical condition diagnosed before purchasing the insurance policy, which may have a waiting period of 1 - 4 years.
Cashless Claim: A claim type where the insurer directly settles the medical bills with a network hospital.
Reimbursement Claim: A process where the policyholder pays medical bills first and later submits documents to claim reimbursement.
Discharge Summary: A hospital document detailing treatment, diagnosis, and discharge status, required for insurance claims.
FAQs
Inform the insurer, provide policy details at a network hospital, get pre-authorisation, and the insurer will directly settle eligible bills.
Review the rejection reason, correct errors, submit missing documents, and file an appeal with supporting evidence if necessary.
Yes, but maternity benefits typically have a waiting period of 9 months to 4 years, so early policy purchase is recommended.
Some insurers allow a waiting period reduction for an extra premium, subject to specific terms and conditions.
Disclaimer - This article is issued in the general public interest and meant for general information purposes only. The views expressed in this blog are solely those of the writer and do not necessarily reflect the official policy or position of Canara HSBC Life Insurance Company Limited or any affiliated entity. We make no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability, or availability with respect to the blog or the information, products, services, or related graphics contained in the blog for any purpose. Any reliance you place on such information is therefore strictly at your own risk. You should consult with a qualified professional regarding your specific circumstances before taking any action based on the content provided herein.
