A Guide on Time Limits in Health Insurance Claims Process

Having a health insurance plan in these times has become very crucial. As medical inflation rates increase, the need to have a financial backup for medical issues is paramount. Ishita, 29, is a young working professional who takes her finances and her responsibilities seriously. This is why she bought a health insurance policy for her parents only after thorough research and comparisons.

A health insurance plan offers more than just hospitalisation coverage. It allows one to have better peace of mind so that the focus can be on rest and recovery instead of financial woes.

To benefit from health insurance during a medical emergency, one has to raise a claim with the insurance company. Each company has a specified time limit within which you are expected to inform them about the medical issue and raise the claim. 

What is the Time Limit for Health Insurance Claim Settlement in India?

In India, the time limit for health insurance claim settlement varies depending on the insurer and whether it is a cashless or reimbursement claim. As per IRDAI guidelines, insurers should settle cashless claims within 30 minutes of receiving all required documents from network hospitals. Reimbursement claims typically take up to 15 days from the date of submission of all relevant paperwork. Bajaj Allianz General Insurance Company is known for its prompt settlement processes, offering customers timely support and a seamless claims experience through a network of 18,400+ cashless hospitals across the country.

Top Factors That Impact Health Insurance Claim Processing Time

• Type of Claim (Cashless vs. Reimbursement): Cashless claims are faster, especially at network hospitals, while reimbursement claims take more time due to document verification.
• Completeness of Documentation: Missing or incorrect paperwork can lead to delays in the claim processing.
• Hospital Network Tie-Up: Claims from non-network hospitals may require more scrutiny and hence take longer.
• Pre-Authorisation Delays: Delay in receiving pre-authorisation from the insurer can impact the time taken to process cashless claims.
• Claim Amount: Higher claim amounts may undergo additional checks, increasing settlement time.
• Policy Terms & Conditions: Waiting periods or exclusions in the policy can lead to claim rejections or extended processing times.
• Medical History and Pre-existing Conditions: Claims involving complex medical history might require detailed assessments.
• TAT of the Insurer: The insurer’s internal claim turnaround time (TAT) standards play a crucial role. Bajaj Allianz General Insurance Company, for example, is reputed for fast and transparent claims processing.

Health Insurance Claim Time Limits and Cashless Settlement Process

Firstly, it is important to note that claim time limits can differ from insurer to insurer. Even within one insurance company, the time limits may depend on the type of health insurance plan chosen.

With Bajaj Allianz General Insurance, the time limits for cashless and reimbursement claims are as follows:

• For cashless claims, the insured or their representative must inform the insurance company before 48 hours if they are opting for planned hospitalisation.
• For emergency hospitalisation under the cashless facility, the insurance company must be informed within 24 hours.
• In both cases, the insured or their representative must request pre-authorisation via from the eEmpanelled network hospital side.
• For reimbursement claims, the insurance company must be informed by the policyholder or their representative 48 hours before the planned hospitalisation.
• For emergencies, the time limit for reimbursement claims is also 48 hours. The insurer must be informed within this period after the hospitalisation takes place.

Additionally, insurance companies also have time limits for submission of documents. For instance, under the Health Guard plan from Bajaj Allianz General Insurance, the policyholder or someone on their behalf must submit the required documents for the reimbursement claim within 30 days of the discharge from the hospital.

*Claims are subject to terms and conditions set forth under health insurance policy.

Also read: Medical Inflation and Its Effect on Health Insurance Premiums

Cashless and Reimbursement Claim Settlement Time

If you are not familiar with the terms ‘cashless’ and ‘reimbursement’ regarding health insurance claims, here is a brief explanation:*

• In a health insurance cashless claim, the medical hospitalisations bills are taken care of directly by the insurance company. The payment process is mainly handled between the insurer’s representative and the network hospital (i.e., hospitals empanelled with the insurer where cashless facilities are available).
• In a reimbursement claim, the policyholder pays the medical bills to hospitals and then files a claim with the insurance company.

*Claims are subject to terms and conditions set forth under health insurance policy.

Essential Documentation for Claim Settlement

When filing an insurance claim, it is crucial to provide accurate and comprehensive documentation. Being honest and thorough can significantly enhance the chances of your claim being processed smoothly. Below is a list of essential documents required during claim submission:

• Detailed Claim Application: A formal claim request outlining the details of the incident.
• Discharge Card: Proof of discharge from a hospital or medical facility, if applicable.
• Bills: Original copies of all relevant bills, including medical, repair, or service invoices.
• Reports: Supporting reports such as medical records, diagnostic tests, or damage assessments.
• Prescription Details: If applicable, include doctor’s prescriptions related to the claim.

Why Time Limits Are Crucial for Health Insurance Claims

Wondering what role time limits play in health insurance? Read on:

1. Allows Faster Claim Settlement

If you raise a claim on time, it allows the insurer to start the due process and begin the verification process on time as well. In case the insurer requires additional details or documentation, they can request for the same, either from the insured or the network hospital and receive it on time. Delays in raising the claim could lead to eventual issues in the later processes as well delays in the settlement of the claim. Consider this: Your health insurance provider does not have a time limit. In such cases, if you are busy taking care of the patient, you may forget to raise a claim or delay it. This would slow down the entire process. The document submission would be postponed, and the reimbursement might be delayed, too.

Hence, having and following time limits in Health insurance is important for faster claim settlement.

2. Ensures Swift Payment

When it comes to cashless claims, as explained earlier, the payment is handled by the insurer. If they receive the intimation or the cashless request on time, they will be able to inform the insured or the hospital for the further process (medical or otherwise) on time too. If the claim is not raised on time, the hospital dues will not be paid on time, either. In such a situation, the patient could face challenges with further treatment or discharge. Hence, time limits on health insurance claims are crucial.

*Claims are subject to terms and conditions set forth under health insurance policy.

3. Reduces Chances of Fraud

Time limits can help mitigate fraud claims. With a strict duration to raise a claim, fraudsters do not have enough time to create false information and raise fraudulent claims.

Important Points to Remember When Raising Health Insurance Claims

Now that you may have a fair idea of time limits, let’s look at other important aspects of health insurance claims:

• If you have a family health insurance plan, make sure all the insured members are aware of the claim process. This includes the claim raising process as well as the time limits, documents to be submitted, essential contact numbers, and so on.
• Be honest with your insurer. Insurance relies on good faith between all the parties involved. Hence, be truthful with your insurance provider about your medical history, any pre-existing illnesses, any major changes in lifestyle or medical updates, and so on.
• Have all the necessary documents in one place. It is understandable that you might be busy with the hospitalisation procedures. However, please take some time to gather and organise the needed documents so that it is easier to raise a claim.

*Claims are subject to terms and conditions set forth under health insurance policy.

Additionally, it is important to pay premiums on time. Before you buy a plan, remember to use a health insurance premium calculator.

Importance of Choosing the Right Insurer

With numerous certified insurance web aggregators available, policyholders now have access to tools for comparing policies before making a purchase. However, while comparing policies, it is vital to consider more than just premium amounts. Focus on coverage, features, and the insurer’s credibility.

1. Tips for Choosing a Credible Insurer

• Seek Recommendations: Consult friends, family, or trusted sources for their experiences.
• Check Online Reviews: Read customer feedback and ratings to gauge satisfaction levels.
• Research the Insurer: Visit the insurer’s website, review their claim settlement ratio, and understand their process.

2. Trust and Transparency in Insurance

Insurance operates on the principles of trust, honesty, and transparency. To ensure a positive experience:

• Be Honest: Provide accurate information while filing a claim.
• Be Patient: Allow the insurer sufficient time to process and settle your claim.
• Have Faith in Your Insurer: Trust your chosen insurance company to act in good faith during claim settlement.

Also Read: Reimbursement Health Insurance: What You Need To Know

Conclusion

Timely settlement of health insurance claims is crucial to ensure that policyholders receive the necessary financial support without added stress. While IRDAI sets general timelines, factors such as claim type, hospital network, and document accuracy significantly influence the duration. Being informed and prepared can make the process smoother. Opting for insurers with a proven track record—like Bajaj Allianz General Insurance Company, which offers a vast network of 18,400+ cashless hospitals—ensures efficiency and peace of mind during medical emergencies.

FAQs

Is there a time limit to claim health insurance?

Yes, health insurance claims typically must be filed within 7 to 30 days after hospitalisation, depending on the insurer's terms.

What is the maximum time for an insurance claim?

The maximum time to claim varies by policy but is generally between 7 and 30 days from the date of treatment or hospital discharge.

Is there a time limit to claim on insurance?

Yes, most insurance policies specify a claim submission timeframe, usually within 30 days of the incident or treatment.

Can insurance companies reject claims after 3 years?

No, as per the IRDAI’s rules, insurers cannot reject claims after three years of the policy being active unless there is proven fraud or non-disclosure of facts.

Is the timeline different for network and non-network hospitals?

Yes, cashless claims at network hospitals are usually processed faster, often within 30 minutes, whereas non-network claims involve reimbursement and take longer.

Do pre- and post-hospitalisation claims have different timelines?

Yes, post-hospitalisation claims are typically filed after discharge and may take a few additional days to process compared to in-hospitalisation claims.

* Standard T&C apply.

Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.