Tata Capital > Blog > Insurance Blogs & Financial Protection Guides > Health insurance claim process: Simplifying your coverage
28 October 2026
9 mins read
2219
Health insurance serves as an asset in times of medical emergencies. However, just purchasing a policy is not enough. You must understand how to access insurance money in case of medical emergencies and treatments. For this, you must familiarize yourself with the medical insurance claims processing steps.
Being unaware of the nitty-gritty of the health insurance claim process can make it difficult to get the claim money when needed, creating stress and panic during a medical emergency.
But worry not. In this article, we’ll guide you through the healthcare claims processing steps to ensure a hassle-free experience.
You can file a claim for your medical expenses in two ways:
– Cashless claim: It allows you to receive medical care at a network hospital without making any upfront payment. Depending on your policy terms and coverage, the insurer will directly coordinate with the hospital to settle the bill.
– Reimbursement claim: This typically applies when you receive medical treatment at a hospital not a part of the insurer’s network. In this case, you have to pay for the expenses yourself and seek reimbursement from the insurer.
Also, read – Which is Recommended, Individual or Corporate Health Insurance?
Now that you’ve understood the medical claim’s meaning, you must know how to complete a mediclaim application. Documents play a vital role in filing a medical claim. They allow the insurer to verify your treatment, expenses, and policy details.
You must always submit clear and accurate documents. If your documents successfully prove your claim, your application is approved faster, and the chances of rejection are reduced. Therefore, remember to keep copies of medical and policy papers handy, especially during hospitalization or after discharge.
The list of documents required for filing reimbursement medical claims in India is as follows:
When you visit a non-network hospital of your insurer, you can opt for a reimbursement claim. Here, you pay the bills first and then get reimbursed by the insurance provider.
A reimbursement claim functions as a backup for cashless claims. Follow this step-by-step guide to make a reimbursement claim for your medical expenses:
Step 1: Inform the insurer
Even if you intend to file a reimbursement claim after the treatment, you must notify your health insurance provider as soon as the treatment begins at the non-network hospital.
Step 2: Apply for a reimbursement claim
Collect and fill out the reimbursement claim form for the application process. You can get it at the hospital’s insurance desk or submit an online form if the insurer offers the facility.
Step 3: Collect the necessary documents
Along with the claim form, you will also have to submit documents like original bills and receipts of hospital and medicines, hospital discharge card, policy copy or insurance card, reports of tests conducted during, pre-, and post-hospitalization, Medical Certificate, and prescriptions signed by the doctor, etc.
Make sure you have the complete list of documents required in one place.
Step 4: Submit the documents
Submit the claim form along with all the documents online or offline. After receiving the documents, the insurer/TPA will verify them and reimburse the funds to your account.
Also, read – Group Health Insurance: Meaning, How It Works, Benefits
With the cashless claim facility, you can get medical treatment at any network hospital without worrying about the funds. Here’s how:
Step 1: Know about your policy
Carefully read the inclusions and exclusions of your health insurance policy to clarify what is covered and what is not.
For instance, some insurers do not cover pre-existing diseases. Similarly, if you had diabetes before purchasing the policy and made a claim for diabetes treatment costs, the claim would be rejected.
Thus, knowing the exclusions and inclusions will help avoid claim rejection and confusion.
Step 2: Know the list of network hospitals
The second step is to be aware of the network hospitals of your insurer. You must visit a network hospital to receive medical treatment via a cashless claim. Show your health insurance card to get admitted and receive treatment. Your insurance provider will directly settle the bills with the hospital. Since the cashless claim facility is only available for network hospitals, you must select an insurer with a wide network.
Step 3: Inform your insurer
Before getting admitted to the network hospital or starting treatment, inform the insurer about the procedure. You can do this through a dedicated helpline number or by filling out the pre-authorization form.
Step 4: Fill out the pre-authorization form
Collect the pre-authorization form from the hospital to proceed with your cashless claim. The TPA/insurer will help you fill it out. Here, while you are not required to submit documents like hospital bills or prescriptions, you will have to present your cashless health card and identification proof.
Step 5: Submit the form
After filling out the form, submit it to the insurance desk. The TPA will then process your application and send you a confirmation email. It will also send a letter authorizing the maximum treatment cost.
Also, read – 6 Key benefits of insurance on loans
A health insurance claim can be rejected for various reasons. While it’s essential to learn how to claim medical insurance, it is also vital to know about the common reasons for rejection so that you can avoid them.
The following tips can teach you how to claim health insurance successfully:
Here are the steps on how to check medical insurance status:
If you’re not comfortable with the online process, you can call the customer care number for assistance. Make sure you save all emails and messages from the insurer and regularly follow up until the claim is approved or settled.
Also, read – Types Of Credit Insurance In India
Several experts can help you if your medical claim is rejected or delayed. You can start by contacting the insurance company’s customer care or grievance cell. Next, your insurance agent or broker can provide guidance on how to claim health insurance. If the issue is still not resolved, you can approach the insurer’s grievance officer.
The Insurance Ombudsman is another professional who can help with your health insurance claim. You can reach out to them via email. The IRDAI also offers support to policyholders through its grievance portal.
When it comes to the hospital insurance claim process, there are a few things that you must keep in mind to make informed decisions. These include:
#1 The sum insured limit
Based on your policy, you can only seek coverage up to a certain amount from your health insurance. If your medical bills exceed this limit, you will have to bear the additional expenses.
Thus, when filing your health insurance claim, check the sum insured limit in advance to avoid any confusion.
#2 Timeline
There are specific timelines that you must follow to get your claim.
In the case of a cashless claim, there is a deadline for submitting the pre-authorization form, which is typically 3-4 days before the treatment for a planned hospital visit. In the case of emergency hospitalization, the deadline is 24 hours post-hospitalization. If you don’t meet the deadlines, your claim can be postponed.
#3 Validity of the policy
You can only make a claim if your health insurance policy is active. Therefore, make sure to check its validity to experience an easy, unrestricted health insurance claim procedure. You can contact the insurer’s customer care and give them your policy details to check its status.
Health insurance helps you deal with hefty expenses comfortably in times of medical emergencies. But you must be well-versed with the medical insurance claims processing steps to reap the benefits of your policy.
You must also carefully select the right insurer that provides 24/7 customer service and will guide you through the process.
This is what we at Tata Capital do. We help you file a claim online and guide you through the process to ensure a seamless experience.
Most health insurance policies have a waiting period of 2 to 4 years for certain claims, though this may differ between insurers. Always review the policy’s terms and conditions to understand the waiting period before purchasing.
Health insurance can be claimed in all hospitals except those specifically excluded by the insurer. Cashless claims are available only in network hospitals, while non-network hospitals require you to pay first and apply for reimbursement.
You can claim up to the sum insured of your policy, but sub-limits may apply for specific treatments. Additionally, some conditions may have a waiting period before they are covered.
Under Section 80D of the Income Tax Act, you can claim deductions of up to Rs 25,000 annually for premiums paid for yourself, your spouse, and dependent children. If the policy is for a senior citizen, the deduction limit increases to Rs 50,000 per year.
Experts recommend a health insurance policy with a sum insured of Rs 5 to 10 lakh. However, it is essential to choose a coverage amount that suits your health needs and can comfortably cover medical expenses, as one amount may not fit everyone.
In a cashless claim, the insurance company pays the hospital directly, provided it is a network hospital. In a reimbursement claim, you pay expenses first and later get the money back from the insurer.
The common documents required to file a medical claim in India include a filled claim form, hospital bills, discharge summary, doctor’s prescriptions, diagnostic reports, policy copy, ID proof, and bank details for reimbursement.
Health insurance claims are usually settled within 15 to 30 days after submitting all required documents. There can be delays if documents are missing or require verification.
Your health insurance claim can be rejected due to non-disclosure of pre-existing illnesses, policy lapse, excluded treatments, incorrect documents, delayed submission, or claims exceeding the sum insured limit.
Yes, you can file a reimbursement claim if treated at a non-network hospital. In this case, you will need to pay the bills upfront and later submit all required documents to the insurer.
Most insurers have a medical insurance claim time limit, requiring you to notify them within 24 to 48 hours of hospitalization. Besides, you must submit documents within 7 to 30 days after discharge. The time limit varies depending on policy terms.
You can track claim status online through the insurer’s website or mobile app using your claim number. You can also contact customer care or check updates via email or SMS.
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