Health insurance has become a need than a want, especially during these uncertain times. There is no guarantee when an individual can get sick. Along with the illness comes the cost of the treatment which is another headache for the patient. Therefore, every individual should be medically insured.

Read this blog to understand the basics of health insurance, how insurance is to be claimed, types of insurance and role of TPA in an insurance claim.

What is Health Insurance? 

Health insurance is an agreement where the insurance company agrees to ensure compensation of medical expenses if the person insured falls ill or meets an accident. These insurance companies have tie-ups with the hospitals to provide cashless treatment to the insured. If the insurance company does not have a tie-up with the concerned hospital, they reimburse the cost of expenses incurred by the person insured. 

It is important to get health insurance for your family and yourself because health care is expensive now. A good health insurance policy would usually cover expenses made towards doctor consultation fees, medical tests’ costs, ambulance charges, hospitalization costs and even post-hospitalization recovery costs to some extent.

Basic terminology 

Hospital: Any institution that is set up for patient care and treatment of ailments and diseases/injuries. It is registered with local authorities under the Clinical establishment act, 2010. It must qualify certain criteria such as: 

  • Trained and qualified nursing staff under its employment round the clock. 
  • Has a certain number of beds depending on the population of the town or place. 
  • Have well qualified medical practitioners in charge round the clock.
  • Have all the basic facilities and well-equipped operation theater to conduct operations. 
  • Maintain patient records that are easily accessible. 

Hospitalization: Hospitalization means admission in the hospital for a minimum of 24 hours in-patient care except for some specified treatments where such admission could be for a period of fewer than 24 hours. 

Copay: Co-payment or Copay means sharing a cost under a health insurance policy where it says that the policyholder will bear a certain percentage of the admissible claim amount. A co-payment does not reduce the sum insured.  

Pre-existing diseases: Pre-existing disease (PED) is any condition, ailment, disease or injury which is diagnosed by the doctor within 48 months prior to the date of the policy issued. By the insurance company. It means any symptoms have resulted within three months of issuing the policy in a diagnostic illness or medical condition. 

30 days waiting period: It means the period from the inception of this policy during which specific disease or treatment is not covered. On completion of 30 days period, treatment shall be covered provided the policy has been continuously renewed without any break. 

Daycare treatment: It is the process of medical treatment which is undertaken under general anesthesia or local anesthesia in a hospital or daycare center in less than 24 hours due to technological advancement. Out-patient procedures might not be included under daycare treatment.

Pre hospitalization Expenses: These expenses include various charges related to medical tests before the patient gets hospitalized. There are various tests performed to diagnose the condition before prescribing a treatment.

Post hospitalization: It means the medical expenses incurred during a period immediately after the patient/policyholder is discharged from the hospital provided (number of days subject to policy t&c).

Portability:  Portability is the right to an individual health insurance policyholder, that includes all the family members covered under the family cover policy, to transfer the credit gained for pre-existing conditions and time-bound exclusions from one insurer to another. 

Why do you need Health Insurance? 

Health is wealth. Today, with the type of lifestyle that most of people lead, health insurance acts as a financial backup. No one wants to get ill, but diseases can come without knocking your doors. One hospitalization can dig holes in your pocket and exhaust your savings. That is the reason health insurance is becoming increasingly important to protect family members and yourself. Before that, try and understand how your policy will pay for the claim. Contact our insurance specialists for a hassle-free claim experience. 

Now, what do you think is the best health insurance policy?

When you get health insurance, what is the best way to decide the best health insurance policy? Everyone has different requirements for health insurance and looks for the best plan. They look for the best medical facility along with maximum payout for the premium they paid every year. 

Health Insurance Claim Status

You have to pay for your medical treatment in case of a planned or unplanned situation. When you opt for treatment, the first thing that comes to mind is to claim health insurance to recover the medical expense. But you can not sit back and relax and wait for the insurance company to take the rest of the process forward. The policyholder needs to check the claim status to avoid delays and rejections. There are different situations or status of a claim: 

  • In progress
  • Query
  • Rejected
  • No status
  • Approved

Consult our insurance specialists to get the maximum payout against your claim. Get your documentation reviewed to get a hassle-free experience.

How to avail claim when needed?

Know health insurance claim via cashless or reimbursement procedure.

Two ways to avail your Hospitalization claim 

  • Cashless
  • Reimbursement

Cashless Claim

In the cashless claim, the insurance holder does not have to pay the bill in case of hospitalization. The insurer will pay the hospital directly on your behalf according to the terms and conditions of the policy. Here are the steps for the cashless health insurance claim: 

  • Planned Hospitalization:

    If the date of your surgery or treatment is fixed or you are well aware of the hospitalization, follow the steps to claim medical insurance: 

    • Inform the insurance company about the treatment to verify the eligibility to claim the medical insurance. You need authorization prior to the hospital admission.
    • The insurer receives your claim request through your insurance card number and informs the hospital giving them a confirmation email or letter. 
    • The patient provides all the treatment reports and doctor consultation documents to the insurance company. 

After the hospital receives the authorization request, they send an estimated cost involved in the treatment that may increase. In such a situation, the hospital sends an estimated new figure to the insurance company. This process is known as Enhancement During Admission. 

    • If there are any discrepancies during hospitalization, the insurance company will raise a query to the hospital that needs to be resolved within 24 hours. The hospital shall submit the necessary documents to resolve the query raised. If the hospital fails to resolve the issue, the pre-authorization may stand rejected and the patient might have to proceed with the reimbursement claim procedure. 
    • Otherwise, the insurance company verifies all the documents for admission, financial parameters and medical certificates, the insurance company makes the payment directly to the hospital. This is a Cashless Process. 
  • Emergency Hospitalization:

    Emergency hospitalization is where you are admitted suddenly or unexpectedly such as an accident. The same procedure is followed where the insurance company must be informed within 24 hours of the admission to avail the claim. You need your insurance card, patient ID proof and cashews claim form. In case of rejection, you may get an email or mobile number registered with the insurance company. 

When is a cashless claim likely to be rejected?

You must check certain things to ensure that your cashless health insurance claim is not rejected. The situations when it might get rejected are: 

  • If the hospital you choose for the treatment is not the network hospital. It means your cashless claim is not allowed at all the hospitals. 
  • If the health insurance policy has lapsed.
  • If you fail to submit a pre-authorization request on time (24 to 48 hours before hospitalization depending on the situation).
  • If the hospital does not provide sufficient information to the insurance company. 

There may be a situation where your insurance approval may be less than the amount you claim. Hence, Pristyn Care insurance specialists will go through the documents and advise a suitable plan of action to get maximum coverage on your claim. 

Reimbursement Claim

If the hospital you choose for the treatment is not part of the network hospitals or does not provide a cashless claim facility. In the reimbursement claim process, you will have to pay the bills at the time of hospitalization and the insurance company will reimburse the medical bill later. Here are the steps for the reimbursement health insurance claim: 

  • Claim Intimation: The patient or the family member must inform the insurance company that he/she is going to claim reimbursement for the treatment. It can be 3-4 days prior to the planned hospitalization or within 24 hours of Hospitalization in case of an emergency condition. 
  • Complete documents required to submit to get reimbursement claim paid-
    • Duly completed claim form
    • Valid photo identification proof of the patient
    • Medical practitioner’s certificate advising admission
    • Original bills with proper breakups
    • Original Payment receipts
    • Original Discharge papers/summary
    • Diagnostic reports supporting diagnosis
    • NEFT details and canceled cheque with printed name of Proposer/main policyholder
    • KYC of the Proposer/main policyholder if the claim amount is above Rs. 1Lakh 
    • FIR/MLC copy in case of an accident
    • Any other relevant documentation required for assessment of the claim by the TPA/Insurance company.
  • Submit all the documents to Pristyn Care by email/uploading on our portal/courier all Original claim documents (as mentioned above) as and when required.
  • After the verification of all the documents as per the policy t&c by our Insurance specialist, a complete claim file gets dispatched to concern TPA / Insurance. Subject to policy t&c TPA / insurance company approves the reimbursement claim and pays the amount back to the holder. 

Hence to get the maximum justified payout on time and avoid any delays or rejections or unwanted deductions, you can contact Pristyn Care Insurance specialist for complete guidance.

When is a reimbursement claim likely to be rejected?

You must check certain things to ensure that your reimbursement health insurance claim is not rejected. The situations when it might get rejected are: 

  • If the health insurance policy has lapsed.
  • What does the policy cover – diagnosis, treatment, or/and medicine?
  • You must have all the documents that include a certificate, test reports, bills and discharge papers from the hospital. Submit them to the insurance company as soon as you get discharged. Missing papers or documents may delay or lead to rejection of the reimbursement. 
  • When the documents reach the insurance company, they are reviewed. They may raise a query regarding the documents or treatment. You must respond to the query or your claim shall get rejected. 

To avoid discrepancies in the deductibles mentioned in the policy and to know the intricacies of the claim process beforehand, contact Pristyn Care insurance specialists. 

What is the role of TPA in health insurance?

TPA stands for third party administration which means intermediate firm between the insurance company and the insurance holder. It provides all the assistance needed to avail health insurance such as claim processing and reimbursement. Here are the different roles of TPA in health insurance: 

  • Claim processing and settlement
  • Reviewing the request for medical treatment and confirming if it is covered under the policy.
  • Provider network management that manages the operations of the insurance company hospital network helping them choose the cost-effective way for treatment. 
  • Enrolment of IDs to make claim procedure hassle-free
  • Cashless process


Health insurance has now become one of the basic necessities. However, getting approval for an insurance claim is tiring. The amount of paperwork can make a person think twice before opting for health insurance. Fortunately, Pristyn Care takes care of the end-to-end process for an insurance claim. Contact us today to know more about which diseases are covered under medical insurance.