"Health Insurance Claim Settlement Guide: What’s Covered, What’s Not & How to File Easily"

 

🏥 How to Settle a Health Insurance Claim in India: What’s Covered, What’s Not & Key Insights

Health insurance gives peace of mind during medical emergencies—but claim settlement is where the real test begins. Many policyholders are shocked when they don’t get the full amount claimed. This blog will guide you step-by-step through the health insurance claim process and help you understand what is covered vs. not covered.

🧾 Types of Health Insurance Claims

1️⃣ Cashless Claim

• Available only at network hospitals listed with your insurer.
• You pay minimal or nothing at the hospital.
• The insurer settles the eligible amount directly.

2️⃣ Reimbursement Claim

• Use any hospital, even if not in insurer’s network except Excluded Provider Network.
• Pay the bill first, then submit all documents to the insurer.
• Insurer verifies the documents and reimburses the approved amount.

📋 Step-by-Step Health Insurance Claim Process

📌 Cashless Claim Process

1. Get admitted to a network hospital.
2. Present policy card or e-card at the help desk.
3. Hospital sends pre-authorization request to insurer.
4. Insurer sends approval or query.
5. Hospital starts treatment.
6. After discharge, the hospital shares the final bill with insurer.
7. Insurer settles the bill directly (you pay non-covered charges).

📌 Reimbursement Claim Process

1. Get treatment at any hospital.
2. Keep all original bills, reports, prescriptions, hospital indoor case papers, insured photo, pan, aadhar and cancel cheque.
3. Fill out and sign the claim form.
4. Submit documents online or to the insurer’s office/TPA.
5. The insurer verifies everything and transfers the admissible amount to your bank account.

✅ What is Covered Under Health Insurance? (Admissible Claims)

Category                                   Example

Hospitalization Expenses  Room rent, ICU charges, nursing, oxygen, etc.

Doctor/Surgeon Fees         Surgeon, anesthetist, visiting doctors

Pre-Hospitalization           Expenses 30 days before admission (diagnostics, doctor consult)

Post-Hospitalization         Expenses up to 60–90 days after discharge (follow-up, meds)

Day-Care Procedures       Cataract, dialysis, chemotherapy, etc.

Ambulance Charges         As per policy limit

Medicine & Consumables  Prescribed by the treating doctor during hospitalization

AYUSH Treatment             If explicitly mentioned in the policy (Ayurveda, Homeopathy etc.)

💡 Note: Always check your policy terms. Many policies have specific sub-limits and conditions.

❌ What is NOT Covered (Non-Admissible Items)

Not Covered           Examples

Consumables      Cotton, gloves, tissue paper (unless covered under special policy)

Registration/Admin Charges    Hospital entry/admission fees

Non-Medical Items   Thermometer, slippers, hot water bag, toiletries, AC/TV charges

Cosmetic Procedures   Liposuction, Botox, plastic surgery (unless due to accident)

Dental, Hearing, Vision   Unless required due to injury/accident or covered explicitly

Self-inflicted injuries   Suicide attempt or substance abuse-related treatment

Unproven/Experimental Treatment   Stem cell therapy (unless part of covered disease)

Pregnancy & Childbirth   Unless you have a maternity rider

Pre-Existing Diseases   Not covered during the waiting period (3–4 years usually)

Specific Diseases  Not covered during the waiting period 2 years.

OPD Expenses   Unless included in an OPD add-on/rider

🧠 Real-World Example

You have a health insurance policy with:

• ₹5,00,000 sum insured
• ₹5,000/day room rent limit
• 2% co-pay

You get admitted for 4 days in a room costing ₹10,000/day.

Your bill:

• Room rent: ₹40,000
• Doctor fees: ₹15,000
• OT Charges: ₹50,000
• Medicine: ₹10,000
• Admin charges: ₹3,000
• Non-medical (gloves, tissue): ₹1,000

Total: ₹1,19,000

How claim is calculated:

• Room rent limit exceeded → claim is proportionately reduced
• Non-medical & admin charges are non-admissible
• Final amount = ₹1,19,000 - (Non-medical + proportionate deduction + co-pay) 

Final payout: approx. ₹90,000 (not full bill)

⚠️ Hidden Clauses You Must Watch

• Room Rent Capping: Affects other claim parts (doctor fees, OT charges).
• Disease-Specific Capping: e.g., max ₹20,000 for cataract.
• Co-payment Clauses: You bear a % of claim, often in senior citizen policies.
• Waiting Period: Some specific diseases covered only after 2 years, and pre-existing diseases covered after 3 - 4 years.
• Maternity Clause: Covered only after 2 years in some plans (if at all).
• Agreed Network Hospitals (ANH) Package: If you are admitted to an open billing package under your planned hospitalization instead of the ANH package, you will be charged more and you will only receive the acceptable package amount from the company. (e.g. ANH package for Gall Bladder Stone 75000/-, but hospital bill amount - 1.15lakh because you admitted to an open billing package. Company will pay only 75000/- and you have to pay the rest of amount i.e. 40000/-)

💼 Tips to Maximize Your Claim

1. Choose rooms within your policy limit.
2. Prefer network hospitals for hassle-free cashless claims.
3. Keep every medical report and bill—even prescription slips.
4. Review policy wordings annually to understand changes.
5. Consult your advisor before hospital admission if possible.

📌 Final Thoughts

Understanding what is admissible vs. non-admissible can prevent surprises at discharge. A good advisor can help you choose the right policy and guide you at the time of hospitalization.

✅ Stay informed. Stay protected. Use your policy wisely.

Hi, I’m Soumyajit.

For over 19 years, I’ve had the privilege of guiding more than 1,400 happy clients across Kolkata through the world of insurance and financial planning. Whether it’s life and health insurance, mutual funds, NCDs, or general coverage along with a claim settlement track record that’s close to 100%—my goal has always been the same: to offer honest, personalised advice you can trust.

If you're looking to protect what matters most, secure your future, or grow your wealth with confidence—I’m here for you, every step of the way. Let's connect