Cashless (network hospital) vs reimbursement. Pre-authorization + documents + TPA. Avoid rejection: full disclosure, understand waiting periods + sub-limits. 80D deduction.
HEALTH CLAIM TYPES: (1) CASHLESS: at NETWORK hospital. Insurer pays hospital directly. No upfront payment (except non-covered). (2) REIMBURSEMENT: at NON-NETWORK hospital. You pay first, claim later with bills. CASHLESS PROCESS: (1) Show health card at network hospital. (2) Hospital sends pre-authorization to TPA/insurer. (3) Approved → cashless treatment. REIMBURSEMENT: (1) Pay hospital. (2) Collect all bills + discharge summary. (3) Submit claim within 15-30 days. STRATEGIC: prefer network hospitals for cashless convenience.
CASHLESS PRE-AUTHORIZATION: (1) PLANNED hospitalization: pre-auth 48-72 hours before. (2) EMERGENCY: within 24 hours of admission. (3) Hospital TPA desk submits form to insurer. (4) Insurer reviews + approves estimated amount. (5) Treatment proceeds cashless. (6) Final bill settled at discharge (additional approval if exceeds). DOCUMENTS: (1) Health card + ID. (2) Doctor's recommendation. (3) Estimated cost. STRATEGIC: inform insurer ASAP. Network hospital TPA desk handles process. Keep policy number + card ready.
CLAIM REJECTION REASONS: (1) PRE-EXISTING DISEASE within waiting period (2-4 years). (2) NON-DISCLOSURE of medical history at purchase. (3) WAITING PERIOD (initial 30 days, specific diseases 2 years). (4) EXCLUSIONS (cosmetic, dental, self-inflicted). (5) ROOM RENT exceeding sub-limit. (6) DELAYED claim submission. (7) Treatment not medically necessary. (8) Documentation incomplete. AVOID: (1) FULL disclosure at purchase. (2) Understand waiting periods + exclusions. (3) Choose right room category. (4) Submit complete documents on time. STRATEGIC: honesty at purchase prevents future rejection.
CLAIM DOCUMENTS: (1) Duly filled CLAIM FORM. (2) DISCHARGE SUMMARY. (3) Original HOSPITAL BILLS + receipts. (4) DOCTOR's prescriptions + reports. (5) DIAGNOSTIC reports (lab, X-ray, etc.). (6) PHARMACY bills. (7) Health card + ID + policy copy. (8) For reimbursement: bank details (NEFT). (9) FIR (if accident). SUBMIT: within 15-30 days of discharge. STRATEGIC: collect ALL originals at discharge. Keep photocopies. Submit complete set to avoid delays/rejection. Track claim status online.
HEALTH CLAIM STRATEGY: (1) PREFER NETWORK hospitals (cashless). (2) DISCLOSE all medical history at purchase (avoid rejection). (3) UNDERSTAND waiting periods + exclusions + sub-limits. (4) CHOOSE no room-rent-capping policy (avoid proportionate deduction). (5) PRE-AUTH for planned, inform within 24h for emergency. (6) COLLECT all bills + reports + discharge summary. (7) SUBMIT within time limit. (8) 80D deduction on premium (₹25K self + ₹50K senior parents). (9) NO-CLAIM BONUS for claim-free years. (10) SUPER TOP-UP for high coverage. (11) ESCALATE wrongful rejection (IRDAI ombudsman). STRATEGIC: right policy + full disclosure + network hospitals + timely claims = smooth experience. Read policy fine print.