What Documents Do You Need to File a Health Insurance Claim?

Health Insurance Claim: What Documents Do You Need After Discharge or Treatment Completion?

When filing a health insurance claim request with the insurer, you’ll need to submit the following documents –

• Duly filled claim form
• KYC documents confirming the identity and address of the concerned person
• Photo identity proof of the patient
• Investigation/Diagnostic test reports supported by relevant prescriptions
• Medical practitioner’s prescription explicitly advising hospital admission (in case of hospitalisation)
• Sticker/invoice of the implant , wherever applicable
• OT notes or Surgeon’s certificate citing details of the operation performed (required in surgical cases)
• Payment receipts for every medicine, diagnostic test, consultation, etc.
• Original hospital bill with itemised breakdown
• Discharge summary of the patient including the patient’s medical history and other key details
• Legal heir/successor certificate (where necessary)
• Medico-Legal Report (MLR) or FIR copy in case of accident-related injuries
• Bank details, such as a cancelled check or NEFT details (for direct credit of the approved claim amount)

If the claim liability is above ₹1 Lakh, then KYC (identity proof with address of the policyholder) documents must be submitted as per the AML guidelines.

These are a few standard documents that you’ll need to submit during the health insurance claim process. You may be asked for additional documents by the TPA or insurer for proper assessment of the claim, so remain flexible with the documentation process. You can prepare by keeping every original medical bill and health report.
 

Why Are Documents Important for a Health Insurance Claim?

If you’re wondering why you need the health insurance claim documents mentioned in the previous section, the points below will clear up your doubts.

● Establishing Medical Necessity

Insurers need documents like doctor’s prescriptions, diagnostic reports, and discharge summaries to determine why the treatment was required and what medical care the patient actually received.

These records help the insurer assess whether the hospitalisation/treatment/a particular medical procedure met the policy’s coverage conditions.

● Verifying the Claimed Expenses

Itemised hospital bills, pharmacy invoices, and payment receipts help insurers verify the claimed amount. They use them to identify expenses that may fall outside the policy’s coverage, such as certain non-medical charges, deductibles, and amounts exceeding applicable sub-limits.

● Checking Policy Compliance

Insurers require all crucial documents to determine whether a particular expense is eligible for approval. It also helps prevent fraud, where an individual might try to claim more than the expenses incurred. Original bills eliminate the possibility of fraudulent claims.
 

Health Insurance Claim Process: When Should You Submit Your Documents?

You must notify the insurer about hospitalisation within a prescribed timeline. In case of planned hospitalisation, you must share full details with the insurer/TPA at least 48 hours before the scheduled admission. For emergency hospitalisation, you can notify the insurer within 24 hours of hospitalisation or before the insured person’s discharge from hospital, whichever is earlier.

If you’re filing an official claim with the insurer for reimbursement of incurred medical expenses, you must submit the relevant health insurance claim documents within 15 days of hospital discharge. It applies to reimbursement of hospitalisation, day care, and pre-hospitalisation expenses.

For reimbursement of post-hospitalisation expenses, you should try to submit all required documents within 15 days of the post-hospitalisation treatment.

For cashless claims, documents are usually shared faster because the TPA is involved and shares key documents directly with the insurer. We suggest checking the policy papers thoroughly to find the right timeline for document submission.
 

Reimbursement Claim Documents: What Should You Submit?

If you’ve availed hospitalisation, day care, or other treatments at a non-network hospital, you’ll have to pay all expenses from your own pocket initially. As a policyholder, you must notify the insurer of the hospitalisation within 24 hours from the date of emergency hospitalisation or before the insured person’s discharge, whichever is earlier. This timeline is applicable for emergency hospitalisation.

For planned hospitalisation, you should share the claim notice with full details at least 48 hours before the scheduled hospitalisation date. You’ll need to share the same documents for reimbursement claims as you would have shared for cashless claims.

Reimbursement claim documents such as a correctly filled claim form, all payment receipts, diagnostic reports, and itemised hospital bills, are generally required for claim assessment. If any additional documents are needed, the insurer will communicate it to you.

These are a few standard documents that insurers usually ask. Depending on your specific case, they may also seek additional documents.
 

Cashless vs Reimbursement Claim: What’s Different?

Both cashless and reimbursement claims have the same documentation requirement. You’ll need documents that prove how much you’ve spent on medicines, room rent, surgery, diagnostic tests, or other healthcare services.

You also need a prescription specifying the need for a particular treatment and documents showing the patient’s health condition before and after treatment. The only difference between the two claims is the involvement of a Third-Party Administrator (TPA).

A TPA usually shares the pre-authorisation form, medical records, bills, discharge summary, and other key cashless claim documents directly with the insurer, so you may not need to provide them separately. As a policyholder, you’ll mainly need to share your health insurance card, ID proof, and any other requested details.

For reimbursement claims, you’ll have to share the same documents directly with the insurer, without any TPA’s involvement. You should check the insurer’s health insurance claim checklist to determine which documents are needed for a smooth health insurance claim settlement.
 

How to Submit Health Insurance Claim Documents

Health insurance claim documents can be shared directly via the insurer’s official email address. You can attach both the duly filled claim form and relevant documents to the email ID shared by the insurer.

If you’re still unsure or need help submitting documents, you can contact the insurer’s customer support team. If you have a health insurance policy from Shriram General Insurance, you can contact our customer support by calling 1800-300-30000; this is our toll-free number for policyholders.
 

Common Mistakes to Avoid When Submitting Claim Documents

Since the health insurance claim process involves submitting numerous documents, some policyholders can get overwhelmed, making mistakes that can delay their claim approval.

If you want a fast, smooth claim approval, ensure you don’t make the following mistakes when submitting health insurance claim documents.

● Submitting Incomplete Documentation

You should first make a list of all the documents that need to be submitted during claim filing. Note, organise, and place them together for quick upload. Avoid submitting documents in a rush, as it may lead to incomplete documentation, which can delay the claim approval.

● Uploading Only Photocopies When Originals are Required

People should keep original invoices, payment receipts, and other documents. Insurers may sometimes ask for original documents instead of photocopies. If you don’t keep the originals, you can create unwanted complications in claim processing.

● Providing Inconsistent Information

If the shared documents show inconsistencies, you may face claim rejections. Hence, don’t make the mistake of sharing unrelated or old medical reports and bills. Share the relevant and latest documents that facilitate seamless verification and approval.
 

Conclusion

Having a valid health insurance plan is a smart way to secure access to healthcare services, despite the rising medical inflation. However, merely having health insurance isn’t enough. You should also be well-informed of the policy’s claim process and relevant documents needed during the claim process. It can make claim assessment easier and faster.

We’ve listed all the key health insurance claim documents generally required during claim filing in this blog, so save it for future reference. If you’re looking for a dependable health insurance plan that provides sufficient coverage, then consider exploring our Shri Health Suraksha Insurance plan.
 

FAQs

What documents do I need during the health insurance claim process?

You’ll need several documents, including the medical bills, diagnostic reports, pharmacy invoices, doctor prescriptions, and hospital bills with an itemised breakdown.

Do I need to submit original medical bills for claim verification?

It depends on a case-by-case basis. It’s best to keep the original bills and reports, as the insurer may ask for originals instead of photocopies.

Will a Third-Party Administrator (TPA) share all key documents with the insurer?

Yes, a TPA will share all essential documents directly with the insurer if you’re availing a cashless treatment facility in a network hospital. For treatment in a non-network hospital, you’ll have to share the documents directly with the insurer.

What happens if I submit incomplete documents?

If you fail to submit all the necessary documents, then the claim process can become complicated. You may face delays in claim verification, and also may face claim rejections (in some cases).

Can I submit health insurance claim documents online?

Yes, you can. Visit the insurer’s official website and file your claim online. You’ll be able to see the option to upload all documents in the subsequent steps of a claim filing process