Health Insurance Claim Process — Step by Step
Health insurance claim ka complete process Hindi-English me — cashless hospitalization, reimbursement, documents, time limit, common rejection reasons. IRDAI-compliant guide.
Health insurance claim 2 types hote hain: (1) Cashless — network hospital me direct insurer pay karta hai, (2) Reimbursement — tum pay karke baad me claim file karte ho. Cashless ke liye 24 hours pehle pre-authorization lena padta hai (planned) ya 24 hours within (emergency). Reimbursement me bills, discharge summary, prescription, IDs sab original me 30 days within submit. Insurer 15-30 days me decision deta hai. Rejection ki most common reasons: pre-existing disease waiting period, policy lapse, non-disclosure, hospitalization criteria not met.
Step-by-Step Process
Yeh complete process hai jo proven aur compliance-safe hai. ProWiderKart facilitator hai — final approval respective lender/insurer/PSP ki discretion par.
Cashless Vs Reimbursement Decide Karo
Network hospital me admission ho rahi hai toh cashless preferred — out of pocket nahi. Non-network hospital ho toh reimbursement claim later karna padega. Emergency me kahin bhi admit karo, baad me reimbursement file kar sakte ho.
Pre-Authorization (Cashless) Lo
Planned hospitalization ho toh 24-48 hours pehle network hospital ke TPA desk pe pre-auth form fill karo. Insurer 4-6 hours me approval deti hai. Emergency me admission ke 24 hours within pre-auth lo.
Documents Tayyar Rakho
Cashless: policy card, photo ID (Aadhaar/PAN), pre-auth approval letter, KYC docs. Reimbursement (additional): all hospital bills original, discharge summary, prescription, lab/test reports, doctor's notes, payment receipts, NEFT details for refund.
Hospitalization Period — Sab Bills Collect Karo
Hospital stay ke dauran har receipt, prescription, test report, pharmacy bill keep karo. Discharge ke time discharge summary aur final bill carefully check karo — koi entry galat ya missing toh hospital se correct karwao.
Cashless: Discharge Pe Settlement
Insurer approved amount hospital ko direct pay karta hai. Tum sirf non-covered items pay karte ho (room rent excess, non-medical items). Settlement letter le lo discharge ke time.
Reimbursement: 30 Days Within Claim File Karo
All original documents claim form ke saath insurer ke office me submit karo (courier/online portal). Acknowledgment receipt zarur lo. Insurer 15-30 days me decision deti hai. Approve hone par NEFT credit ho jata hai.
Frequently Asked Questions
Cashless claim reject ho gaya — kya kare?
Pehle rejection reason letter dhyan se padho — generally pre-existing disease (PED) waiting period, non-disclosure, ya non-covered procedure hota hai. Reimbursement claim try karo with full documentation. IRDAI Ombudsman tak escalate kar sakte ho if unjust.
PED waiting period kya hota hai?
Pre-existing disease (jo policy lene se pehle diagnosis hua) ke liye most policies 2-4 years waiting period rakhti hain. Iske baad coverage start hota hai. Yeh IRDAI guidelines ke under hai.
Insurance ke kitna time baad claim kar sakte hain?
Most policies 30-day initial waiting period rakhti hain (accidents excluded). Specific illnesses (hernia, cataract, joint replacement) ke liye 1-2 year waiting period. PED ke liye 2-4 years.
Reimbursement me kitna time lagta hai?
IRDAI guidelines per: insurer ko 30 days me decision dena padta hai post-document-submission. Delay ke case me interest payable hai. Status TPA portal pe track kar sakte ho.
💬 Free Advisory Chahiye?
WhatsApp pe contact karo. Free consultation. Multiple option compare.
💬 WhatsApp Now