How Many Days to Claim Health Insurance?

Time Frame for Filing a Health Insurance Claim

Health insurance are subject to various timelines that outline how long the insurance company would take to settle the claim. Settling the health insurance claim may take several days or a few weeks, depending on the nature of the claim, whether cashless or reimbursement, the nature of hospitalization, and the procedures followed by the insurance company.

Following is a breakdown of the different timelines typically followed.

1.Cashless Health Insurance Claim Settlement
Cashless claims enable the insured to get medical treatment without any upfront payment, and the insurance company directly settles the bill with the network hospital. Cashless claims tend to take less time compared to reimbursement claims.

●Claim Intimation: As soon as hospitalization is required, the policyholder is expected to inform the insurance company or TPA. Generally, the intimation must be done 48 hours before planned hospitalization, whereas during emergency hospitalization, it must occur within 24 hours.
●Claim Approval: After receiving the claim intimation, the insurer (or TPA) will scrutinize the details, which may take 2 to 4 hours for emergency claims. For planned hospitalizations, the approval may take 1-2 working days.
●Settlement Time: After approval, the insurance company will settle the claim directly with the hospital. Usually, this happens within 24 to 48 hours.

2.Reimbursement Health Insurance Claim Settlement
In a reimbursement claim, the policyholder pays for the incurred medical expenses and then submits the related documents to the insurer for settlement. The period taken to settle the reimbursement claims takes longer than in the case of cashless claims, as it also involves more documentation and processing.
●Claim Intimation: The policyholder has to notify the insurance company about the hospitalization within 24-48 hours. However, it is advisable to inform as soon as possible to avoid delay.
●Submission of Documents: After the treatment, the policyholder must submit all the necessary documents, including hospital bills, discharge summaries, and medical reports. Insurers generally require these documents to be submitted within 30 days of discharge.
●Claim Processing: When the claim documents reach the insurer, normally, it takes 7 to 10 working days for the claim to be processed. However, if the documents aren't complete or the claim is complicated, settlement usually takes longer.
●Settlement Time: If the document is perfect, normally, reimbursement arrives within 15 to 20 working days.
Factors Affecting Claim Settlement Time
Several factors influence the health insurance claim settlement time. Understanding these factors can help policyholders expedite the process:
●Claim Complexity: Simple claims with minimal documentation are processed faster than complicated ones involving high treatment costs, pre-existing conditions, or prolonged hospitalization.
●Documentation: The accuracy of the completed documents submitted for reimbursement claims directly impacts the settlement time. Missing documents or discrepancies often lead to delays.
●Pre-authorization Process: The insurers might take time to check the pre-authorization request, depending on the terms and conditions of the policy. Therefore, this also delays the claim processing timeline.

Claim Settlement in the Event of Disputes or Rejections
 

At times, there is a rejection or dispute regarding the claims submitted. Such situations cause delays in the claim settlement process. Rejection grounds include:

●Failure to declare pre-existing ailments
●Treatment that is not included in the insurance policy
●Insufficient or inappropriate documentation

If the claim is declined, the policyholder may appeal the decision by lodging a grievance with the insurer or directly approaching the Insurance Ombudsman.

At Star Health, to ensure faster settlement, we process all claims in-house. This enables us to settle 90% of cashless claims in under 2 hours and 92% of reimbursement claims within 7 days, subject to terms and conditions.   

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