How to File a Claim for Individual Health Insurance Coverage?

Individual Health Insurance

Healthcare insurance policies in India come with the advantage of reimbursement, making people stress-free from the formalities. But there can be instances when your individual health insurance plan may need the hospital or the clinic under its network from where you may need to get your treatment done.

In those situations, you will have to file a claim. This blog will tell you everything related to claims for health insurance for individuals.

What are Medical Claims?

A medical claim is a request made by the policyholder to take care of the medical expenses incurred during their treatment at the hospital. As per the mediclaim policy for individuals, the insurance company will either settle the bill with the hospital or ask the policyholder to provide reimbursement details. Depending on the insurance plan and the company, claims can be as under:

Cashless Claims

Cashless claims in an individual health insurance plans mean that once you get admitted to the hospital for your treatment, your insurance company will take care of the bills and settle them directly with the hospital. In case you have the cashless claim facility, you will have to follow the below steps to get your claim approved:

  • Choosing the hospital empanelled in the insurance company’s network would be best.
  • In case of a planned admission – inform the TPA (Third Party Administrator) team and give all details.
  • In an emergency – inform the TPA team as soon as you are admitted.
  • Fill out the cashless form at the hospital and get it certified by the doctor.
  • Submit your filled form to the TPA team along with any required documents.
  • The TPA team will send the documents with the estimate to the insurance company for approval.
  • Insurance companies will review the documents and approve or reject them accordingly.
  • If approved, the insurance company will settle the bill directly with the hospital, and you will be discharged post-settlement.
  • If rejected, the insurance company will request more documents for claim approval.


If you have chosen a hospital not part of the insurance company’s network, you must use the reimbursement option for your claim. Reimbursement means you will have to pay for your treatment expenses and later submit all the medical bills, doctor’s bills, fees, and other documents as the insurance company asks for the claim. In addition, you will have to follow the below steps for the reimbursement process:

  • You must contact your health insurance policy company and inform them about your admission.
  • At the time of discharge, settle all the bills with your hospital.
  • Collect all the prescriptions, bills, discharge summary and all the other documents during discharge and present them at the time of reimbursement.
  • The insurance company will help you download the reimbursement form to fill out.
  • You must fill out the form and submit it with the required documents.
  • If your claim is approved, the insurance company will disburse your claim amount to you as per your preferred method.

What are The Things to Remember During The Claim Process?

Whether you go for cashless or reimbursement, there are a few things you should remember during the claim process:

  1. You should carefully fill out the cashless and reimbursement form. Any mistake can lead to the rejection of the claim.
  2. As per your individual health insurance plan, check for when you must raise the reimbursement request for the claim to get approved.
  3. Remember, the non-payable items are not reimbursed in either of the cases.
  4. Ensure to follow all the steps carefully and keep all your documents in place.

What are The Different Documents Required During The Claim Process?

The following set of records may be needed to process your refund claim:

  • Duly-filled claim form
  • Doctor’s prescription
  • Treatment papers
  • Investigation reports
  • Medical bills
  • Medicine bills
  • Discharge summary
  • Insurance card
  • Cancelled cheque
  • PAN and Aadhar cards
  • Diagnosis synopsis
  • Investigation reports confirm the treatment.
  • Doctor’s certificate

Nowadays, a best health insurance in india is is highly required and people should buy them without any misses. However, the most comfortable way of claiming is always cashless, but if you cannot get your treatment done in a hospital listed on the panel, go for the reimbursement process.

Remember to keep all your documents in place, as the insurance company can ask you for any medical paper during the process. Also, ensure to fill out your claim form carefully; any details that need to be corrected can lead to rejection.


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