Health Insurance Claims Explained: What to Do Before, During and After Hospitalisation

Buying health insurance is only one part of insurance planning.

The real test comes when you need to use it.

A medical emergency is already stressful. Having to understand your insurance claim at the same time can make the situation even harder.

Understanding the health insurance claim process before hospitalisation can help you respond more confidently when the need arises.

What Is a Health Insurance Claim?

A health insurance claim is a request made to the insurer for payment of eligible medical expenses under your policy.

Depending on your policy and circumstances, treatment may involve a cashless claim at a network hospital or a reimbursement claim.

The exact process depends on the insurer and policy terms.

Cashless vs Reimbursement Claims

Cashless Claim

Under a cashless arrangement, eligible treatment at a network hospital may be settled directly between the insurer/TPA and hospital, subject to approval and policy conditions.

You may still have to pay expenses that are not covered.

Reimbursement Claim

In a reimbursement claim, you generally pay the eligible hospital expenses first and then submit the required documents to the insurer for reimbursement, subject to the policy terms.

Read UNC’s detailed guide on Cashless vs Reimbursement Health Insurance Claims to understand the distinction.

What Should You Do Before Hospitalisation?

If the situation allows, don’t wait until admission to look for your policy documents.

Know:

• Your insurer
• Policy number
• TPA details, where applicable
• Network hospitals
• Claim notification process
• Required documents
• Pre-authorisation requirements

Save these details somewhere accessible to your family.

Planned Hospitalisation

For planned treatment, you may have more time to prepare.

Check whether:

• The hospital is part of the current network
• Cashless treatment is available
• Pre-authorisation is required
• The treatment is subject to a waiting period
• Any exclusions apply
• Your sum insured is sufficient

Contact the insurer or relevant claims channel before admission where possible.

Emergency Hospitalisation

In an emergency, treatment comes first.

Insurance formalities should not delay necessary medical care.

Once the immediate situation is under control, notify the insurer/TPA according to the policy’s claim notification requirements.

Keep relevant documents and bills safely.

Documents You May Need

Depending on the claim, documents may include:

• Policy details
• Identity documents
• Hospital bills
• Discharge summary
• Doctor’s prescriptions
• Diagnostic reports
• Investigation reports
• Payment receipts
• Claim forms
• Other documents requested by the insurer

The exact requirements vary.

Always follow the insurer’s current instructions.

Why Claims Get Complicated

A claim isn’t simply about whether you have a health insurance policy.

It can depend on:

• Policy coverage
• Waiting periods
• Exclusions
• Medical history
• Sum insured
• Sub-limits
• Co-payment
• Documentation
• Disclosure made at the time of purchase

This is why understanding your policy before a claim matters.

Don’t Hide Medical Information

When buying health insurance, provide accurate information about relevant medical history.

A policy is built around the information provided during underwriting.

Incomplete or inaccurate disclosure can create complications later.

Being transparent at the beginning is safer than trying to save a little money on the premium.

What If a Claim Is Delayed or Rejected?

First, understand why.

Ask for the reason in writing and review it against the policy terms.

Keep copies of:

• Claim correspondence
• Bills
• Medical records
• Reports
• Insurer communications

If you need assistance understanding the process, professional insurance guidance can help you navigate the next steps.

UNC Insurance and Claim Guidance

At UNC Insurance, we believe insurance advice shouldn’t end after the policy is purchased.

A protection relationship should also help you understand what happens when you actually need to use the policy.

Our approach focuses on helping clients understand their coverage, documentation and claim-related processes.

If you are reviewing your health insurance before renewal, don’t just compare premiums.

Understand the claim journey as well.

Frequently Asked Questions

What is a cashless health insurance claim?
It generally allows eligible treatment expenses at a network hospital to be settled through the insurer/TPA process, subject to policy conditions and approval.

Does cashless mean the entire bill is covered?
No. Non-covered expenses, deductibles, co-payments, exclusions and other applicable costs may still be payable.

What documents are required for a health insurance claim?
Requirements vary, but commonly include bills, discharge summary, prescriptions, reports, claim forms and policy-related documents.

Can I claim from health insurance without hospitalisation?
Coverage depends on the policy. Some plans may cover specified day-care procedures and other eligible expenses.

What should I do if my claim is rejected?
Understand the reason for rejection, review the policy wording and follow the insurer’s applicable grievance or appeal process.