Health Insurance Claim: How To Claim Medical Insurance Online (2024)

Health insurance is designed to mitigate your medical care costs and provide you with a cushion if your health fails. There could be different situations when you may have to make a claim against your policy. This could be due to a planned or unplanned hospitalisation.

There are two ways you can raise a claim against your policy: Cashless or Reimbursem*nt Claims. But, the procedures for these two types of health insurance claims are different, and it is vital that you understand their guidelines for a hassle-free experience.

A health or medical insurance claim is a process of requesting the insurer (in this case, ACKO) to provide the benefits and services covered in your health insurance policy. You can either opt for a cashless claim (also known as direct claim settlement) or a reimbursem*nt claim for medical expenses incurred.

There are three types of health insurance claims. These are as follows.

Under this type of health insurance claim, the insurer (ACKO) settles all the medical expenses (as covered by the policy) with the hospital directly. However, to avail of the cashless mode of claim settlement, the policy’s beneficiaries need to be hospitalised at a network hospital.

You can also utilize our cashless facility even if the hospital is not part of the Acko network. This initiative aims to ensure smooth health services for our customers. If you are planning for hospitalization or in case of emergency hospitalization at a non-network hospital, please request the hospital to send the cashless request in the specified format (download thePreauthorization request form)to our support email ID[emailprotected]for further assistance. We would connect with the hospital for onboarding as a network provider, to be able to process your request for a cashless facility further. You may contact us at our helpline number1800 266 2256or email us at[emailprotected]for any assistance.

To initiate this process, the healthcare provider should submit a pre-authorization request using the specified format, which must be emailed to the aforementioned email ID within a specified time period. For planned hospitalization, this should be done 48 hours before admission and in case of emergencies, within 48 hours of admission, so as to allow us time for onboarding formalities of the provider.

Under this type of health insurance claim, you pay the hospitalisation bill first and then file for the reimbursem*nt of the hospitalisation expenses. The insurer (ACKO) will pay the amount to you as per the terms and conditions of the policy.

• Choose from the list of network hospitals as specified in the policy document.

• Approach the hospital’s insurance help desk at least 72 - 48 hours before admission and provide your policy card to initiate the claim process.

• Fill the pre-authorisation form and other forms as required.

• If the case is found admissible, ACKO will settle the hospital bills up to the approved amount as per the terms and conditions of the policy.

If a cashless claim is not sanctioned, you can pay the bills and file for reimbursem*nt of the medical expenses.

Here are the steps for the cashless claim process in case of emergency admission.

• Approach the insurance help desk at the hospital and provide your policy card.

• Fill the pre-authorisation form to initiate your cashless claim.

• If the case is found admissible, ACKO will settle your claim directly with the hospital after considering the deductibles.

If the cashless claim is not approved, you can file for reimbursem*nt.

Here is the process for reimbursem*nt of the hospitalisation bills.

• Inform your insurer (in this case, ACKO) about the medical treatment and the details of the hospital.

• Avail of treatment at a hospital of your choice.

• Settle all the hospital bills.

• Ensure you obtain the original hospitalisation documents such as discharge summary, diagnostic and laboratory reports, prescriptions, payment receipts, etc.

• Download the health insurance claim form from our website and duly fill in all the required details. Ensure the hospital attests all the documents with seal and signature. You can refer to the section below for the list of common documents required to make a claim.

• Apply for the reimbursem*nt claim online or by writing to us.

• Submit all the hospitalisation-related documents along with the health insurance claim form.

• If your claim is sanctioned, ACKO will settle your claim as per the terms and conditions of the policy. If your claim is not approved, ACKO will communicate the reason for the rejection.

Note: In both types of claims, you must inform ACKO before or while seeking hospitalisation.

Here is the list of common documents required while making a claim against your health insurance policy. However, documents may differ depending on the case.

1. Duly filled health insurance claim form.

2. Discharge summary of the patient

3. Cash invoice

4. Prescriptions

5. Diagnostic reports (ECG/X-Ray/Scans/Laboratory)

6. First Information Report (FIR) or Medico-legal Certificate (MLC) in case of an accident

7. Copy of the insurance policy

8. Original medical bills

9. Original payment receipts

10. Canceled cheque in case of reimbursem*nt claims

For the reimbursem*nt of the hospitalisation bills, you can raise your claim against your policy through our online platform or by writing to us. For more details, you can refer to our article on the step-by-step guide for raising a health insurance claim.

It is ideal for securing yourself and your family with adequate health insurance to mitigate the rising medical expenses. You may have employer health insurance (mediclaim insurance/corporate health insurance) and a personal health insurance policy, or you may have taken two different private health insurance policies. You may be wondering if you can raise a claim from multiple insurance companies. The answer is yes.

All you need to do is make a claim with the first insurer against the medical care expenses. Then, you need to procure the summary of the claim settlement from the first insurer, get the hospital bills and receipts attested by the hospital, and approach the second insurer to settle the balance of your medical expenses.

You must secure yourself and your family with a health insurance policy that offers an adequate sum insured amount to mitigate rising healthcare costs and unforeseen hospitalisation expenses. However, it is also essential to select a dependable insurer. To help you find the right insurer, two ratios that can help you is - Claim Settlement Ratio (CSR) and the Incurred Claim Ratio (ICR).

A Claim Settlement Ratio of an insurer represents the total number of claim settlements against the total number of claims registered in a financial year.

Following is the calculation of the claim settlement ratio in medical insurance.

Claim Settlement Ratio = Claims settled in a year/Claims received in a year x 100

Incurred Claim Ratio represents the net amount of claims settled against the total premium received during the financial year.

Incurred Claim Ratio = Claims settled in a year/Total premium received in a year x 100

Sometimes, a health insurance claim may be rejected, and this can be due to various reasons. Here are the instances under which your health insurance claim can get rejected.

• Non-disclosure of pre-existing conditions

• Fraudulent claims

• Treatment not covered under the policy

• Claim under an expired policy

• Medical expenses over and above the sum insured

• Treatment within the waiting period

• Standard and general exclusions

Disclaimer: The content on this page is generic and shared only for informational and explanatory purposes. It is based on industry experience and several secondary sources on the internet, and is subject to changes. Please go through the applicable policy wordings for updated ACKO-centric content, and before making any insurance-related decisions.