Just like all right things in the world don’t come easy, Insurance policies too come with certain problems. Insurance policies are hard to understand for a layman or someone who does not have any expertise in  Insurance,  and this difficulty magnifies when you have to lodge an insurance claims. However, due  to inadequate information, incomplete documentation or discrepancies in claim process, you don’t want  to face a claim rejection. Therefore, it is crucial to  understand the claim process, how it works and  what documents you need  so as to get maximum pay-out.  To help you sail through the process, we have laid  down everything  you need to  know about  how the claim  process works.

There are two ways to claim health insurance

  1. Cashless
  2. Reimbursement

What is a Cashless Claim in Health Insurance?


A cashless claim is when the policyholder does not have to pay anything out  of his pocket, according  to the terms and conditions of the policy, the entire bill is directly cleared  by the insurance company. A cashless claim can be lodged for both, planned or unplanned medical emergency.

The 4 step for cashless claim resolution


1. Pre-authorisation

In this process, the insurance company verifies  the policyholder’s eligibility to claim. When the policyholder presents the insurance policy card and an official identity card to the hospital, pre-authorisation process is initiated.

After verification of eligibility and hospital needs and the line of treatment is established, is when the cashless claim process begins.

2. Enhancement While Admission

Although the line of treatment and needs of hospital were established during pre-authorisation process, however if due to foreseen  or unforeseen circumstances  the hospital realises that the treatment expenditure maybe higher than previously established expected cost. The hospital needs to send out a new expected figure and this process is called the enhancement while admission.

3. Queries in Cashless Admission

If during admission, any discrepancies are found, the insurance company raises queries to hospital which is  required to be resolved within 24-hours framework. In order to resolve the query, the hospital may need to provide additional supporting documents. Once the query is addressed, the insurer company reassess the claim.  

However, if the hospital is unable to resolve the query then pre-authorisation is rejected and the policyholder is informed to lodge a medial claim via reimbursement.

4. Cashless Discharge

If the query has been resolved and the insurance company has  verified and established all requiring data in line with the terms and conditions of the policy, the insurance company is then required to settle the payment directly.  

What is the Reimbursement Claim in Health Insurance?


The reimbursement claim can be opted when treatment is undertaken in a non-network hospital or if cashless facility is not available at the hospital, the policy holder has to pay for the treatment from his own pocket and then later, claim reimbursement for the same.

A reimbursement claim is lodged only after the discharge process, therefore the policyholder needs to make sure that he/she has collected all necessary documents and kept a copy of every receipt provided by the hospital.

The company will then assess the claim in accordance to the term and conditions and after verification, accept/reject the claim.

The 6 Step Process of Reimbursement Claim


  1. Contact the Insurer Company:- First things first, the policyholder is required to inform the insurance company, ideally within 24 hours of the admission in case of a medical emergency. On the contrary, if it’s a pre-planned hospitalisation then the insured needs to inform the company at least 3 to 4 days prior.            
  2. Ensure to collect all relevant documents :- The burden of presenting all relevant documents for claim approval lies on the policyholder, therefore he/sheis required to collect all the original medical documents and itemized bills and submit them to the insurance company in the order mentioned in the insurance policy.

These documents include -

  • Copy of Gov. Id Proof with Insurance card
  • Original Hospital Discharge Summary
  • Original Itemized Bills
  • Hospital Bill & Breakup
  • Original Investigation Reports
  • Original Pharmacy Bills
  • Original Prescriptions
  • Copy of FIR/Medico-Legal Certificate (only in case of accidental injury)
  • Original Cancelled Cheque

3. Getting the Documents Reviewed by an Expert Agency like Insurance Samadhan

We, at Insurance Samadhan have a bench a professionals who are expert at their work and therefore can verify all documents for you. This is primarily recommended because the insurance company suspects the state of fortuity of occurrence of amoral hazard and cross-verifies every minute detail. Therefore, to save your claim from being rejected, we recommend to get your documents verified.

4. Lodging and Submittingthe Claim Form:- The policyholder can either lodge a claim form by hand, online or via an expert at Insurance Samadhan to ensure that the whole process is error and hassle free. Our experts will ensure that you receive guidance at every step and get maximum pay-out faster. Once all documents are verified and uploaded, the claim can be submitted.

5. Claim Tracking and Query:-  You can track a reimbursement claim via call or through the online portal of the company. If after claim submission, any query is raised by the insurance company then the policyholder is required to resolve the query ideally within 2-3 days.

The policyholder can approach our experts for assistance or advice on resolving the query. Insurance Samadhan is the most trusted platform for resolving Insurance complaints in India. We will overtake the entire process and put you at ease. With our growing family of over 10,000 happy customers, we commit to solving all your insurance related issues.

Claim Approval and Settlement

Once claim is assessed, all documents are verified and queries are resolved, the insurer company approves and settles the payment made by the policyholder by reimbursing all costs incurred by the insured.

Get Resolutions for Insurance Complaints

If you're having any kind of problem while filing for Health Insurance Claim please reach out us to below given details.

To reach us at InsuranceSamadhan.com –

Call us at – 844 844 0626

Mail us at – corporate@insurancesamadhan.com

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