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Types of claim settlements in health insurance

Cashless

It’s possible to get a cashless claim if you’re admitted to a networked hospital, an insurance company-affiliated hospital. All medical bills are handled directly by the insurance company for this type of claim. It only takes the payment of the disallowed expenses or non-covered expenses to settle the claim.

Reimbursement

If you file a reimbursement claim, you pay your own medical bills. Once you have recovered, submit all your bills to your insurance company. The insurance company verifies the bills and then reimburses you for the covered medical costs.

This can happen in the following situations :

  • If you receive treatment at a non-networked hospital
  • For any reason, you cannot submit a cashless claim
  • During pre and post-hospitalization expenses, and claims are settled on a reimbursement basis only. However, the insurance marketplaces don’t assist the customers with this.

At OneAssure, we assist you until you receive the claim amount into your bank account.

The claim settlement process

Cashless Claims

  • 1. First, find a networked hospital through your insurance company's website.
  • 2. Notify your insurer or third-party administrator (TPA) about your claim.
  • 3. Fill out a pre-authorization form for cashless claims, available at the hospital or on the insurer's website.
  • 4. For a cashless claim, you must have these documents kept ready:
    • Pre-authorization claim form
    • Policy health card
    • KYC documents (Aadhar, PAN cards)
    • Doctor's prescription for hospitalization
  • 5. Submit the pre-authorization form:
    • 3-4 days before scheduled hospitalization
    • Within 24 hours for emergency treatment.
  • 6. The hospital's TPA/insurance department manages the process.
  • 7. It is only after the initial approval, does the treatment begin.
  • 8. Ensure the hospital submits bills in advance to avoid any discharge delays.
  • 9. The final approval is based on submitted documentation.
  • 10. Once approved, pay any pending non-payable amounts directly to the hospital for discharge.
  • 11. If the claim is denied, the insurer provides a reason, and you can file for reimbursement.

Reimbursments Claims

If you're anticipating a claim, it's crucial to notify the TPA or insurer in advance. In that case, you’ll be asked to complete a claim form and have these documents submitted:

  • 1. Doctor's prescription for hospitalization
  • 2. Diagnostic/investigative testing reports
  • 3. Comprehensive records and doctor's reports outlining all treatments received
  • 4. Original hospital and medical bills
  • 5. Doctor's prescription confirming recovery and completion of treatment
  • 6. FIR or medical certificate for accidental injuries
  • 7. Aadhar Card & PAN card copies for identification
  • 8. Canceled bank check for claim reimbursement
  • 9. Copies of the policy and insurance card.

About Us

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Reach Us

Prost Insurance Brokers Pvt. Ltd.(OneAssure), 3rd floor, 91springboard, MG Road, Gopala Krishna Complex 45/3, Residency Road, Mahatma Gandhi Rd, Bengaluru, Karnataka 560025.

Phone: ​+91 6364334343

Mail:​ support@oneassure.in

​Prost Insurance Brokers Pvt. Ltd.(OneAssure), 3rd floor, 91springboard, MG Road, Gopala Krishna Complex 45/3, Residency Road, Mahatma Gandhi Rd, Bengaluru, Karnataka 560025.License No. 756, Direct Broker (Life & General), Valid from: 22/07/2021 to 21/07/2024