A Comprehensive Guide on Health Insurance Claim Settlement Time

Medical inflation is rising rapidly, and the best solution may be purchasing health insurance to cope. It is a significant financial tool that covers medical expenses due to illness or accidents.

However, you must adhere to the health insurance claim settlement time specified by your insurer to avail of these benefits. You are expected to inform your insurer about the medical issue and raise the claim within the time limit. 

Explore this article to know why time limits are important in the health insurance claim settlement process.

What is the Time Limit for Health Insurance Claim Settlement in India?

The Master Circular, issued under Section 14(2)(e) of the IRDAI Act, 1999 and Section 34 of the Insurance Act, 1938, has restricted health insurance claim settlement time for both cashless and reimbursement claims. Find out in detail below:

Cashless Claims

The insurer shall decide on the request for cashless authorisation immediately and not more than 1 hour after the request. In fact, an insurer shall grant final authorisation within 3 hours of the receipt of discharge.

Reimbursement Claims

For reimbursement, a policyholder must accept or reject claims within 30 days after submitting all documents. Moreover, the time limit may vary depending on your insurance company and the type of health insurance policy you have.

What are the Time Limits to File a Health Insurance Claim?

Just like the health insurance claim settlement time limits, filing a claim also has time limits.

Time Limit for Raising Cashless Claims

1. For Planned Hospitalisation: If you require admission to hospital for a scheduled medical procedure such as surgery, you must inform your insurer at least 48 hours before admission.

2. Emergency Hospitalisation: If there is an emergency, such as an accident or cardiac arrest, the policyholder must inform the insurer within 24-48 hours of admission to the hospital.

2. Time Limit for Raising Reimbursement Claims

1. Planned Hospitalisation: This is similar to a cashless policy, as policyholders must inform the insurer at least 48 hours before admission.

2. Emergency Hospitalisation: In case of a medical emergency, the insurer must be informed within 24 hours.

Why Time Limits Are Crucial for Health Insurance Claims?

Health insurance claim settlement time matters because it impacts settlement, helps avoid rejection and more.

1. Faster Claim Approval

At first, the insurer must verify the claim, approve it, and settle it. Therefore, on-time claim filing ensures insurers start the verification process immediately. It accelerates claim approval and helps you receive funds faster.

2. Stress-Free Claim Settlement

On-time claim submission reduces the chances of back-and-forth communication. It helps to keep your documents handy and prevent forgetting details. It makes the entire process stress-free. However, you need to submit all documents carefully.

3. Avoid Claim Rejection

Each insurer has a different time limit for filing a claim, and crossing that time limit may result in claim rejection. Henceforth, it is better if you file it as soon as possible. Delays may cause rejection, and you have to bare out of pocket.

4. Prevent Fraud

A strict time limit helps to avoid fraudulent claims. It reduces the chances of manipulation, fake records, and false health information. Therefore, transparency between policyholders and the insurer remains well maintained.

Contact Bajaj General Insurance for faster claim approval and hassle-free claim settlement.

Top Factors That Impact Health Insurance Claim Processing Time

Find out what are the influencing factors of health insurance claim settlement. The claim types, documentation, and more impact it.

1. Claim Types: As there are two types of claims, such as cashless and reimbursement claims, it affects the settlement time significantly. Usually, cashless claims get settled faster than reimbursement claims.
2. Documentation: Complete and accurate documents usually speed up health insurance claim settlement time. Similarly, missing or incorrect papers cause delays.
3. Claim Amount: The value of the claim matters in the settlement time. It may take longer to settle due to additional verification and approval processes, and vice versa.
4. Medical Evaluation: In case the policyholder requires a second opinion, claim processing time may increase.
5. Terms and Conditions of the Policy: If the waiting period is longer, there is a high probability of claim rejection.
6. Claim Settlement Process of Insurer: The claim processing steps of insurers vary, and that also affects health insurance claim settlement time.

What are the Essential Documents for Health Claim Settlement?

Providing accurate documents is crucial for faster mediclaim settlement time. The policyholder must be honest to increase the chances of smooth claim settlement.

1. Detailed Claim Application: A formal claim file must be submitted and filled with details of the incident for both cashless and reimbursement plans.
2. Policy Details: You must provide policy details to make sure the terms and conditions are met.
3. Discharge Card: You must collect the discharge card as proof from a hospital or medical facility. It is mainly applicable for reimbursement claims. 
4. Hospital Bills: You must carry the original copies of all relevant bills, such as medical service invoices, room charges, medicine bills and others.
5. Prescription Details: In some cases, you must consider providing doctor’s prescriptions.

Important Facts to Remember When Raising Health Insurance Claims

Find out the important aspects that you must keep in mind during health insurance claim settlement time.

Awareness for Your Family Members

You must make sure that all family members are aware of the claim process, especially for a family health insurance plan. The information must include time limits, documents, contact numbers and more.

Transparency

The policyholder must be transparent and honest with the insurer. After all, faster claim settlement relies on good faith between all the parties involved. Staying truthful about your medical history, any pre-existing illnesses, or any major lifestyle changes helps get faster claim settlement.

Keep all Documents Ready

Keep all the documents in one place. Understandably, you might be busy with the hospitalisation procedures. However, take some time to gather and organise the needed documents so that it is easier to raise a claim.

Note: Claims are subject to terms and conditions set forth under the health insurance policy.

Why Choose the Right Insurer with Low Health Insurance Claim Settlement Time?

You must find a reliable and reputed insurance provider that has a wide hospital network for cashless facilities, a transparent claim process and more.

Faster Turnaround Time (TAT)

The right insurance company incorporates less health insurance claim settlement time. It helps process verification faster and approve claims without delay. In case of grievance or complaint, a reputed company always takes action faster.

1. A reputed company ensures consumer satisfaction without causing extra delays in claim settlement.
2. Even for reimbursement, faster TAT helps policyholders relieve the financial burden.

Broad Cashless Hospital Network

Cashless facilities are more convenient to follow and less complicated than the reimbursement process. The scope for manipulation and cross-verification is less for both parties. Purchasing health insurance from a reputed insurer helps the cashless process, as they have a wide range of network hospitals in India.

1. Network hospitals provide better transparency in claims.
2. As the process is cashless, claim settlement takes 2-3 hours before discharge.

Transparent Claim Processes

Reputation and trust from both ends are necessary in settling health insurance claims. A reputed company with a high claim settlement ratio usually does not hide any terms and conditions. In the policy paper, the facilities and coverage are described clearly.

1. A transparent claim settlement process helps policyholders in getting the maximum coverage in the best possible way.
2. A reputed company does not reject your claim through manipulation.

Lower Out-of-Pocket Expenses

There are co-payments and sublimit in health insurance. They are cost-sharing features that reduce the premium. However, you have to bear extra costs out of your pocket when claiming under the policy.

1. A reputed company never keeps hidden terms regarding co-payments and sublimit.
2. You can plan your premiums and consider add-ons to get maximum coverage with a reputed company.

Bottom Line

Now you are aware that health insurance claim settlement time depends upon several factors such as claim filing time, type of claims, documentation and more. The insurer must consider final authorisation regarding claim settlement according to the IRDAI guidelines.

However, choosing the right insurer is mandatory for faster TAT so that YouTube claims get settled faster. It also offers a wide network of hospitals for cashless facilities.

Confused about which insurer to trust? Contact Bajaj General Insurance with 18,400+ cashless hospitals for faster claim settlement and reimbursement.

FAQs

What happens if the insurer delays the settlement beyond the legal deadline?

If an insurer fails to settle a claim within 30 days, the company has to pay high interest on the claim amount to the policyholder. The rate remains above 2% of the prevailing bank rate.

How much time do I have to submit original documents for a reimbursement claim?

Policyholders need to submit hospital bills, prescriptions, and the discharge summary within 7 to 15 days from the date of discharge.

Does the choice of hospital impact the turnaround time?

Yes. If you choose network hospitals, the claim will be cashless, requiring less processing time. Conversely, if you choose a non-network hospital, you need to pay the bill out of pocket and get reimbursement within 30 days.

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