Health insurance is a comprehensive policy that carries many benefits that are to be utilized to their full potential to get the maximum benefits out of it. Gone are those days when health insurance plans used to cover only hospitalization expenses such as room rent, surgery costs, surgeon fees, anesthesia fees, etc. Earlier, there used to be too many expenses which are to be borne by the insured themselves from their pocket as the health insurance policy is limited to cover only the medical expenses. Nowadays, health insurance plans cover a wide variety of expenses incurred by insured customers. For example, health insurance plans offer convalescence benefits in the form of a lump sum cash amount if you are hospitalized for more than a certain number of days.
There are other add-ons, such as hospital daily cash, which provides daily cash to the insured customer for a certain number of days. All these additions to the health insurance policy are designed to cover the complete expenses incurred by the insured customer. For example, if you are hospitalized for more than a certain number of days, you would not be able to work, resulting in loss of pay for which the convalescence benefit could act as compensation. In other cases, you need to spend some amount for people visiting you or family members accompanying you in the hospital; in such cases, hospital daily cash benefits come in handy as they provide a certain amount for the number of days you are hospitalized.
We aim to explain to you the various benefits available in a health insurance policy and when and how to claim those benefits. In addition, we also discuss the documents required to avail these benefits from your health insurance policy.
What’s on this page?
Pre Hospitalization Benefit:
How to Claim?
Pre-hospitalization benefits are those that are provided to the insured if only the hospitalization benefit is allowed under the policy. Pre-hospitalization expenses include the amount spent on diagnosis tests such as CT scans, MRI Scans, X-rays, consultation fees, etc. It is important to note that the tests mentioned above, if done after the insured is admitted as an in-patient, would be covered under the in-patient hospitalization benefit. On the other hand, if these tests are done to verify or confirm the disease or illness, then they would come under pre-hospitalization expenses, and these expenses would be covered only if the insurance company accepts the in-patient hospitalization claim.
When to Claim?
Pre-hospitalization benefits can be claimed only when they lead to in-patient hospitalization. For example, your treating doctor may recommend you undergo a CT scan to examine your blood vessels, and after the reports, the doctor may ask you to get admitted as an in-patient to carry out the treatment. In such cases, the CT scan expense would also be covered under the policy. It is important to note that such expenses could be covered only if the insurance company admits the in-patient claim and is to be filled in the health insurance claim form before submitting for claim settlement.
Pre-hospitalization benefits can be availed in reimbursement as well as on a cashless claim settlement basis.
Documents Required:
- Original medical bills of diagnosis tests undergone by the insured.
- Duly filled out and signed the health insurance claim form.
In-patient Hospitalization Benefit:
How to Claim?
In-patient hospitalization benefit is the most important part of a health insurance policy. One can claim in-patient hospitalization benefits if they are admitted to a hospital for more than 24 hours for treatment of an illness, disease, or condition. In-patient benefits can be claimed either in-network hospitals or non-network hospitals. In the case of a network hospital, one has to coordinate with the insurance desk of the hospital and submit the E-card or health insurance policy to get the benefits, whereas, in case of reimbursement, you can get admitted to the hospital, take treatment, and then apply for reimbursement with the insurance company.
When to Claim?
In-patient hospitalization benefits can be claimed only when you are required to undergo treatment as per the advice of a qualified doctor. For example, you might have met with an accident or developed a tumor that needs to be operated on immediately. Then, in such cases, your treating doctor would advise you for in-patient hospitalization, depending on the type of treatment. There could be certain daycare treatments that do not require in-patient hospitalization, and such treatments are covered in a separate section under the health insurance policy.
Documents Required:
- Duly filled and signed claim settlement form
- Attending doctor’s certificate
- Medical documents such as discharge summaries, admission notes, test reports
- Original policy certificate
- Canceled cheque in case of reimbursement.
Post Hospitalization Benefit:
How to Claim?
Post-hospitalization benefits are those that would be available to the insured customer after availing of the in-patient hospitalization. Post-hospitalization expenses can be claimed by filling out the claim settlement form and submitting it to the insurance company. Suppose the expenses are incurred during your stay in the hospital. In that case, they will come in an in-patient hospitalization, but those expenses incurred after your discharge come under post-hospitalization expenses. Post-hospitalization expenses have the limit as that of the sum insured mentioned under the insurance policy.
When to Claim?
Post-hospitalization benefits would be available only in case of acceptance of in-patient hospitalization claims. For example, after discharge from the hospital, you might need to undergo certain follow-up tests, such as X-rays, CT scans, etc., over a certain period of time to track the effect of the surgery or treatment. All such expenses incurred after hospitalization are known as post-hospitalization expenses and would be covered up to a maximum of 180 days. To claim post-hospitalization expenses, you should be admitted as an in-patient.
Documents Required:
- Medical documents such as test reports, original bills, etc.
- Duly filled and signed claim settlement form.
Online Doctor Consultation:
How to Claim?
Online doctor consultation can be availed by dialing the toll-free number of the insurance company, which in turn would connect to the empanelled doctors for consultation. The consultation would be online and one can avail the services any number of times depending on the terms and conditions under the policy. One need not spend anything to avail of these services as the insurance company would arrange everything for the consultation.
When to Claim?
Online doctor consultations are available only in case of consultation requirements and not for any treatments. Consultation refers to the act of seeking assistance from qualified physicians or any healthcare professionals for diagnostic studies or other services that may benefit the patient. Online doctor consultation can be availed if you are in doubt about the treatment suggestion given by your treating doctor or for any symptoms.
Documents Required:
- A request to the insurance company by filling out an online or offline form.
- Original policy document.
Outpatient Treatment:
How to Claim?
Outpatient treatment benefits under the health insurance plan can be claimed by visiting the outpatient department of the hospital. For this, one may either opt for network hospitals or non-network hospitals. Outpatient treatment includes short-term medical care such as blood tests, minor surgeries, bone fracture treatments, medical screenings, etc. After availing of the outpatient treatment, one should contact the insurance company and submit the required documents to process the claim. Outpatient treatment benefits can be availed by getting the treatment first and then submitting the claim documents for reimbursement of the claim amount. If it is a network hospital, one can avail of the outpatient benefit simply by showing and giving the details of the health insurance policy. Still, in the case of a non-network hospital, one needs to spend the amount first and then claim it from the insurance company.
When to Claim?
Outpatient benefits can be availed only when the treatment is on an outpatient basis, i.e., there is no admission to the hospital for treatment. A few examples of OUTPATIENT treatment include doctor’s fees or any other consultation fees; diagnosis costs like X-ray, CT Scan, etc.; wheelchair or crutches; routine check-ups; vaccination; minor surgeries including dressing such as fractures of limbs; dental treatment; hearing aid, spectacles, and contact lenses, etc. In any of these cases one can go for outpatient benefits from the health insurance policy.
Documents Required:
- Original bills incurred for the treatment.
- Original policy document
Domiciliary Hospitalization:
How to Claim?
Domiciliary hospitalization refers to the medical treatment availed by the patient at their home in cases where the patient is unable to visit the hospital for treatment purposes. Domiciliary hospitalization can be availed by submitting a request to the insurance company on the advice of the treating doctor. For this, the claim form should be filled out and submitted to the insurance company. In the case of a network hospital, the entire process of claim settlement would be taken care of by the treating hospital, and in the case of a non-network hospital, one needs to fill out the claim form and submit it for reimbursement of the claim amount.
When to Claim?
Domiciliary hospitalization can be availed in one of two scenarios:
- When the treatment lasts more than 72 hours.
- When the hospitals in the area are full due to some reason (such as a pandemic, epidemic, etc.)
- When the treating doctor recommends domiciliary treatment, taking the patient from the home to the hospital could aggravate the condition of the patient.
In any of these conditions, one can go for domiciliary hospitalization after obtaining the approval of the insurance company. Insured themselves cannot decide on availing the domiciliary hospitalization as the decision rests with the treating doctor.
Documents Required:
- Duly filled and signed claim settlement form
- Attending doctor’s certificate
- Medical documents such as discharge summaries, admission notes, test reports
- Original policy certificate
- Canceled cheque in case of reimbursement.
Donor Expenses:
How to Claim?
Donor expenses refer to the medical expenses incurred by the patient for organ transplants. Donor expenses are incurred as a part of the in-patient hospitalization expenses incurred by the insured patient. Any donor transplantation requires two people to undergo surgery – one is the donor, and the other is the receiver (the insured being the receiver). Donor expenses are a part of the in-patient treatment expenses incurred by the insured, and the same can be claimed using the health insurance claim form. If the donor expenses are incurred in a network hospital, then the claim can be made on a cashless basis. Otherwise, reimbursement mode can be opted for by the insured for a claim by submitting all the relevant documents.
When to Claim?
Donor expense benefits can be availed only in case of requirement, and that too should be suggested by the treating doctor. A donor should be identified by the insured for the treatment, and it is important to note that the insurance company would only pay the cost of the transplantation of the organ and not the cost of the organ. For example, if you want to undergo kidney transplantation, the insurance company would compensate you for the cost of transplantation, including the harvesting expenses, but would not compensate the cost of the kidney (assuming you are purchasing the kidney organ). Organ transplant expenses are a part of the surgery expenses for treating the damaged organs, which usually require replacement.
Documents Required:
- Duly filled and signed claim settlement form
- Attending doctor’s certificate
- Medical documents such as discharge summaries, admission notes, test reports
- Original policy certificate
- Canceled cheque in case of reimbursement.
Ambulance Cover:
How to Claim?
Ambulance cover refers to the expenses incurred by the insured patient for transporting the patient from the accident spot to the hospital or between hospitals for treatment purposes. However, the transportation should be on an emergency basis. Ambulance cover benefits can be availed by booking any of the available private ambulances or a particular hospital’s ambulance to travel to the hospital. After the ambulance facility is available, one should fill in the details of the service available in the health insurance claim form and submit the original bills for claim settlement. There would be a column in the claim settlement form to fill in the details of the ambulance expenses incurred by the patient.
When to Claim?
Ambulance expenses can be claimed only when you avail it on an emergency basis. Ambulance services should be taken for emergencies such as heart attacks, accidents, etc. Road ambulance and air ambulance facilities can be available depending on the availability of the service. For example, if your health insurance policy permits you to avail of an air ambulance, you could do the same to save the time traveled. Air ambulances would be highly useful and relevant in cities with heavy traffic, such as Metropolitan cities.
Documents Required:
- Original ambulance bill.
- Duly filled and signed claim settlement form.
Reset Benefit:
How to Claim?
Reset benefit refers to the restoration of the sum insured to the base limit under the health insurance policy. For example, if you have taken a health insurance plan for Rs.10 Lakhs and used Rs.6 Lakhs for a claim, then under the reset benefit, the insurance company would restore the policy to the original sum insured (Rs.10 Lakhs). Restore benefit is usually automatic nowadays, i.e., restoration is done as and when the sum insured goes beyond the base limit. For the reset benefit to be applicable, there should be a claim leading to the reduction of the sum insured under the policy. It is important to note that reset benefits would not be applicable for the first claim under the health insurance policy. It is important to note that restoration benefits may not be used for the same illness during the policy period in some health insurance plans.
When to Claim?
A reset benefit can be claimed only when the existing insured sum is depleted in a health insurance policy. Basically, the reset benefit is intended to keep the sum insured at the same levels during the policy period. Reset benefit could be availed from the second claim onwards when the sum insured is utilized partially or completely for the first claim in a given policy period. For example, if you have taken a health insurance plan for Rs.10 lakhs with Reset Benefit and made a claim for Rs. 11 Lakhs during the policy period, you would be paid only Rs.10 Lakhs as that is the maximum sum insured available under the policy. After the first claim is settled, a reset benefit would be applicable, leading to the restoration of the sum insured to Rs.10 Lakhs, which can be used for another claim during the policy year.
Documents Required:
- Duly filled and signed claim settlement form
- Attending doctor’s certificate
- Medical documents such as discharge summaries, admission notes, test reports
- Original policy certificate
- Canceled cheque in case of reimbursement.
Complimentary Health Checkup:
How to Claim?
Complimentary health check-up refers to the free health check-up facility that would be provided to the insured customer during the policy period for not claiming during the previous policy period. For example, if you have not made a claim under your health insurance policy, you would be eligible for a complimentary health check-up, which can be availed at any time during the policy period. Complimentary health check-ups can be availed in a network or non-network hospital. If you want to avail of a network hospital, you need to inform the insurance company regarding the same and they would be arranging a hospital that is near to you. If you want to avail it from a non-network hospital, then you should avail the facility first and then claim reimbursement from the insurance company.
When to Claim?
Complimentary health check-ups can be availed at any point during the policy period. One can get to know their health condition by going through the test results of the complimentary health check-up. It is important to note that a copy of the test results will be sent to the insurance company as well. It is a complementary facility offered by insurance companies and can be availed if there is no claim in the previous policy year.
Documents Required:
- Duly filled and signed health check-up form
- KYC documents
- Original policy number/ certificate
Wellness Programs:
How to Claim?
Wellness programs refer to preventive care services such as annual diagnosis, disease screenings, vaccination, exercise, etc. Wellness programs are designed to motivate insured customers to maintain a healthy lifestyle so that they can reduce their lifestyle-related conditions that could lead to hospitalization. Wellness programs are usually offered to every health insurance policyholder, and one need not do anything separately to avail of these benefits. There are some tools, such as mobile apps, that can be installed and used to track exercise behavior, attend online classes for stress reduction, motivation sessions, etc.
When to Claim?
Wellness benefits can be claimed immediately after taking the health insurance policy. The main aim of these benefits is to reduce stress among individuals by improving their lifestyle through programs such as exercise, yoga, stress management therapy, etc.
Documents Required:
- No specific documents are required to avail of this facility.
Hospital Daily Cash:
How to Claim?
Hospital daily cash refers to the amount that the health insurance policy would pay if you are hospitalized for more than a certain number of days. Hospital daily cash benefit offers a lump sum amount that can be utilized by the insured to meet the additional expenses incurred by him/her that are not covered under the policy. One can avail of hospital daily cash benefits by filling out the claim form and specifying the number of days in the hospital. Once the details are filled in the claim form, the insurance company will make the payment directly to the insured customer. The amount of daily cash in the hospital would depend on the number of days spent by the insured patient in the hospital.
When to Claim?
Hospital daily cash benefits can be claimed only if you have been hospitalized for a certain number of days. In general, if you are hospitalized for more than 3 days continuously, you are eligible for the hospital daily cash benefit, excluding the first 3 days of hospitalization. There would also be an upper limit on the number of days per hospitalization the benefit would be applicable.
Documents Required:
- Duly filled and signed claim settlement form.
Convalescence Benefit:
How to Claim?
Convalescence benefits refer to the lump sum amount that is paid to the health insurance policyholder to cover their extended stay in the hospital. Convalescence benefit could be used to compensate for the loss of income due to the extended stay in the hospital. Convalescence benefit could be claimed by filling out the specified column in the claim settlement form, and it would be honored by the insurance company if the hospitalization lasts for an extended period.
When to Claim?
Convalescence benefit can be claimed only when there is an extended hospital stay. For example, if you have been admitted to a hospital for more than 10 days, then you would be eligible to claim convalescence benefits. Some insurance companies offer it as an in-built cover, and others offer it as an add-on. Depending on what kind of coverage is available under your health insurance, you could claim the benefit.
Documents Required:
- Duly filled and signed claim settlement form.
Maternity Benefit:
How to Claim?
Maternity benefit refers to the coverage offered by the health insurance plan towards the medical expenses incurred for all pregnancy-related issues such as normal delivery, c-section, legal termination of pregnancy, etc. Maternity benefit is usually offered as an add-on in a health insurance policy and can be claimed only if there is a female member in the policy. One should inform the insurance company regarding the delivery and may choose to get admitted to a network hospital or a non-network hospital, depending on the situation. In the case of a network hospital, one can avail of the cashless facility by directly getting admitted into the hospital, whereas, in the case of a non-network hospital, one should pay the amount first and then get reimbursed by the insurance company.
When to Claim?
Maternity benefits can be claimed only twice during the life period of the insured policyholder. For example, if you have one child before availing of the maternity benefit, then you could claim only once during your lifetime as the policy states that the benefit would be applicable only for 2 deliveries. If you do not have any children, then you could claim for 2 deliveries under the health insurance policy. Maternity benefits can be claimed for delivery or legal termination of pregnancy. The expenses incurred for delivery would be paid under this benefit in a health insurance policy.
Documents Required:
- Duly filled and signed claim settlement form
- Attending doctor’s certificate
- Medical documents such as discharge summaries, admission notes, test reports
- Original policy certificate, KYC documents
- Canceled cheque in case of reimbursement.
Critical Illness Benefit:
How to Claim?
Critical illness benefit refers to the financial compensation provided to the insured patient in the diagnosis of any of the listed critical illnesses. To avail of critical illness benefits, one should submit the diagnosis report to the insurance company and fill out the claim form. Critical illness benefits may be availed at any point of time during the policy period, subject to the diagnosis being done in India. Critical illness benefits are available as an add-on under the health insurance policy.
When to Claim?
Critical illness benefits can be claimed only when you are diagnosed with any of the mentioned critical illnesses. Since it is an add-on under the policy, the claim can be made only during the validity of the add-on.
Documents Required:
- Duly filled and signed claim settlement form
- Diagnosis report
- Original policy certificate, KYC documents
- Canceled cheque in case of reimbursement.
For more information on how to successfully claim health insurance benefits, please visit Ethika Insurance and talk to our health insurance experts.
