Claim Types

Cashless Claims in health insurance allow policyholders to receive treatment at a network hospital without paying upfront for covered medical expenses. Instead of the insured settling the bill and then seeking reimbursement, the hospital sends the bill directly to the insurance company or its Third-Party Administrator (TPA) for approval and payment. The process typically involves showing your health card or policy details at the hospital, getting pre-authorization from the insurer (in case of planned treatments), or notifying them immediately during emergencies. Once approved, the insurer settles the eligible expenses directly with the hospital, and the patient only pays for non-covered items or costs beyond the policy’s terms. This facility reduces financial stress during medical emergencies, speeds up admission, and ensures smoother treatment without delays caused by payment arrangements.

Reimbursement Claims in health insurance refer to the process where a policyholder first pays all the hospital or treatment expenses out of pocket and then applies to the insurance company to get those costs refunded. This method is typically used when treatment is taken at a non-network hospital or when cashless approval is not possible. To file a reimbursement claim, the insured must submit original hospital bills, payment receipts, discharge summaries, prescriptions, diagnostic reports, and a duly filled claim form to the insurer or Third-Party Administrator (TPA) within the specified time frame. After verifying the documents and ensuring the expenses are covered under the policy, the insurer transfers the eligible amount directly to the policyholder’s bank account. While this process takes more time than cashless claims, it offers flexibility to choose any hospital, even if it’s not part of the insurer’s network, without losing the financial protection of the policy.

Types of Cashless Hospitalisation

Planned Hospitalisation

1 -Consultation & Diagnosis

Visit your doctor. Doctor advises hospitalisation because symptoms have not improved with medication or surgery is required. Obtain a detailed prescription clearly stating the need for hospitalisation.

2- Obtain Supporting Documents

Complete medical diagnosis reports. Doctor’s written prescription for admission. Hospital’s estimated bill for the expected treatment cost.

3-Submit Pre-authorisation Request

Share all documents with the insurance company or TPA (Third Party Administrator) before admission. Submission can be done via the hospital’s TPA desk, email, or the insurer’s online portal.

4-Verification & Authorisation

The insurer/TPA will verify your policy coverage, medical necessity, and cost estimates. If approved, they issue a cashless authorisation letter to the hospital.

5-Hospital Admission

Get admitted on the scheduled date without paying the treatment cost upfront (except for non-medical expenses not covered by insurance). Important: Before buying any health insurance, ensure your policy includes a consumable cover, as this can save you from paying for items often excluded from coverage.

Types of Reimbursement Hospitalisation

Planned Hospitalisation

1-Consultation & Diagnosis

Visit your doctor. Doctor advises hospitalisation because symptoms have not improved with medication or surgery is required. Get a detailed prescription clearly stating the need for hospitalisation.

2-Obtain Supporting Documents

Complete medical diagnosis reports. Doctor’s written prescription for admission. Hospital’s estimated bill for the expected treatment cost.

3-Advance Treatment Payment

Make payment to the hospital before or during admission. Always take a proper payment receipt from the hospital. If you buy medicines from outside, keep both the prescription and the receipt. During treatment, keep all receipts for every expense. At discharge, collect the complete discharge summary, all prescriptions, test reports, and any other documents related to your bill.

4-Submit All Documents

Send all bills, receipts, and reports to your insurance company or TPA for reimbursement.

5-Check the Network Hospital List

Confirm that your hospital is not blacklisted under IRDA.

6-Understand the Claim Process

This is your hard-earned money and financial security—know the process well. Filing claims should give you confidence, not fear of rejection when you need it most.

7-Emergency Hospitalisation

This applies when hospital admission is required immediately, such as in accidents, heart attacks, strokes, or other sudden serious illnesses. Procedure: Immediate Admission Take the patient to a hospital (preferably in the insurer’s network). Provide the patient’s health card or policy details. Emergency Intimation Inform your insurer or TPA within 24 hours of admission. Document Submission Provide emergency admission reports, doctor’s notes, and any test results. Treatment & Discharge Pay the hospital bill at the time of discharge. Collect all prescriptions, test reports, discharge summary, and payment receipts. Claim Submission Send all required documents to your insurance company or TPA for reimbursement.

Documents Needed at the Time of Admission

Step 1: Documents Needed at the Time of Admission

When you reach the hospital, provide these documents at the TPA desk:

Your insurance policy details or e-card.

Copy of Aadhaar Card and PAN Card.

Complete medical diagnosis reports.

Doctor’s written prescription for hospital admission.

Hospital’s estimated bill for treatment.

Step 2: Hospital Intimates Insurance Company

The hospital’s TPA desk will send a pre-authorisation request to your insurance company.

Step 3: Submission & Verification of Claim Documents

Hospital submits the required documents for approval.

The insurance company verifies your claim (usually takes 30 minutes to 2 hours).

Tip: Inform your agent or broker—they can help get faster approval.

Claims may be rejected or partially approved if:

The hospital is blacklisted by IRDA.

Your policy does not allow this type of hospitalisation.

You are still in the waiting period for a pre-existing disease.

Any other reason as per policy terms.

Step 4: Claim Decision

If Approved: Hospital receives an approval email.

If Declined: Hospital receives a rejection email.

Step 5: If Your Claim is Rejected or Partially Approved

Don’t panic! Follow these steps:

1.Understand the reason for rejection or partial payment.

2.Contact the insurance company’s help desk or customer care for details.

3.Discuss with your agent or broker—they can provide professional guidance.

Step 6: If the Problem Persists

Contact Insurance Mart and share:

A copy of your policy.

The rejection letter from your insurance company.

The hospital’s estimated bill.

The doctor’s prescription for admission

Greetings from Insurance Mart.

We understand that a healthy workforce is the foundation of a productive organisation. That’s why we specialise in providing Group Mediclaim Policies—tailor-made health insurance plans that protect employees and their families, while also helping employers control costs and manage claims efficiently.

Employee Benefits

Cashless Hospitalisation – Treatment at network hospitals without upfront payment. Reimbursement Claims – Quick settlement for treatment taken at non-network hospitals. Family Cover Options – Extend benefits to spouse, children, and parents. No Pre-policy Medicals – Hassle-free enrolment. Wellness Programs & Annual Health Check-ups – Early detection for better health outcomes. Financial Security – Peace of mind during medical emergencies.

Employer Benefits

Optimised Cost per Employee – Best coverage at minimum premium. Monthly Claim Reports – Identify negative claim patterns early and take corrective measures. Claim Control Strategy – Avoid unnecessary IPD (In-Patient Department) admissions for cases that can be treated in OPD (Out-Patient Department). Premium Control – By reducing avoidable hospitalisation, we help maintain a healthy claim ratio—ensuring premiums stay stable year after year instead of rising unnecessarily. Documents Required at the Time of Hospitalisation

For Cashless Claims:

Employee health card / policy details. Doctor’s admission advice. Valid ID proof.

For Reimbursement Claims:

Original hospital bills & payment receipts. Detailed discharge summary. All prescriptions & test reports. Any additional documents requested by the insurer/TPA.