Filing a Health Insurance Claim

Last Updated at: Oct 30, 2020
Starting from 1st October, 2020, a lot of health insurance rules have been changed in India. Permanent illness outside the cover will come down to 17 from 30.  No claim will be rejected after 8 years of paying the premium. No re-evaluation will also be applicable for policies where the consumer has paid a premium for 8 years.


Investing in a personal health insurance claim is very important than a group policy from the employer’s side. If you want to file a personal health insurance claim, then you could be confused about what to opt for and what to ignore. In that case, here you will get to know some factors that will help you choose the right claim.

Particularly if you’re making a claim on a personal health plan, as opposed to a group policy from your employer, the insurer can be very strict about the application of its rules. It’s no wonder that insurers are commonly among consumers’ biggest problems. So if you have any reason to make a claim on your insurance policy, ensure you follow these steps:

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1. Try to minimize the cost, even though the expenses are deducted from the insurance cover. A good claim history is in your best interest. Additionally, you would have a higher portion of the insurance cover available for the rest of the period of cover. A large sum claimed would mean a more expensive premium the next year.

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2. Check whether the hospital is registered. An approved hospital needs to have 10-15 beds based on the city you reside in.

3. Inform the TPA (third party administrator) or insurer upon hospitalization. It has been brought to light that insurers have rejected claims on the grounds that they weren’t informed about hospitalization within 48 hours. These norms are laid out in the insurance contract so you cannot lament about the stress caused by hospitalization.

4. In case of a change in treatment, intimate the insurer which has approved the earlier procedure.

5. When inquiring about a room upgrade, ask the hospital whether the higher room rent would be applicable on all days of stay or just the three out of five days you used it, for example. Hospitals usually test your ability to pay and hence when you shift from a double occupancy room (for two days) to a single one (three days), the entire bill shifts to the rates of single room. Doctor visit charges too are increased for the entire period of stay.

6. In case of a cashless claim settlement, check the bill before being discharged and sign it to avert a situation where the hospital submits an inflated bill to the insurer. Inform the third party administrator or the insurer of the final bill amount.

7. Submit documentation in time. Check the policy terms to know the deadlines set for submission. These have been drastically reduced to 5-7 days post discharge.

8. Remember that your food bill and costs associated with your family member staying with you in the hospital won’t be taken care of under the insurance cover.

If you feel, your claim was valid and has been rejected, ask for a written explanation. This would help you fight a legal battle against the insurer.

When filing for a personal health claim, it is important to minimize the cost but you should not compromise on the coverage and period of cover. You need to inquire about the supported hospitals, facilities such as room upgrade, cashless claim settlement and more. You should always have a written explanation of rejections.