Health Insurance · advanced
Health Insurance Claims — In Depth
How a health insurance claim works: cashless and reimbursement, day-care and domiciliary claims, enhancement requests and the TPA's role, second opinions and treatment abroad, why claims are rejected, and fraud.
- 01Cashless Claim Process — Pre-authorization, In-treatment, DischargeHow a cashless health claim moves through pre-authorisation, treatment and discharge, the time limits IRDAI sets for the insurer's decisions, and which parts of a hospital bill the patient still pays.
- 02Reimbursement Claim Process — Documentation ChecklistHow a reimbursement health claim works: when it arises, the documents the policyholder submits, the 15-day settlement rule, how the payable amount is assessed, and what can be done if a claim is filed late or cut.
- 03Day Care Procedures — Eligible Treatments & Claim FilingWhat counts as day-care treatment in a health policy, why it needs cover separate from the 24-hour hospitalisation condition, where it may be taken, and how claims for treatments such as cataract surgery or chemotherapy are filed.
- 04Domiciliary Hospitalization Claims — When Hospital Treatment Moves HomeWhat domiciliary hospitalisation means in a health policy, the two situations in which home treatment qualifies, the conditions each policy sets for itself, and how such a claim is documented and filed.
- 05Claim Rejection Analysis — Common Reasons & How to Avoid ThemWhy health claims are rejected, grouped into policy terms, non-disclosure and procedure, the checks an insurer must complete before rejecting, the 60-month moratorium, and the routes for challenging a rejection.
- 06Claim Enhancement & Negotiation — Working with TPAWhat a claim enhancement is in a cashless claim, how the TPA's role differs from the insurer's, what a policyholder is entitled to when part of a claim is deducted, and how a disagreement is escalated.
- 07Second Opinion & Treatment AbroadWhat a second medical opinion is and how it can change the size of a claim, when a health policy pays for planned treatment outside India, and how a global-cover rider differs from travel insurance.
- 08Health Insurance Fraud — Detection, Prevention & Legal ConsequencesWhat health insurance fraud is, who commits it and how insurers notice it, what a policy and the law allow once fraud is established, and what an intermediary is expected to do when offered a part in it.