Health Insurance Claims — How to File and What to Check
A claim is the moment your policy is actually tested. This guide explains, in plain English, how health insurance claims work in India, what to check in your policy before you need one, and the terms that most often trip people up. CoverSure is an IRDAI-registered advisory — we help you understand your cover; your insurer assesses and settles the claim itself.
Cashless vs reimbursement
There are two ways to claim. In a cashless claim, the insurer settles the bill directly with a network hospital, so you pay little upfront. In a reimbursement claim, you pay the hospital and claim the money back afterwards with the bills and documents. Either way, your policy’s waiting periods, sub-limits and co-payment still apply — which is why it pays to know them in advance.
What to check in your policy before you claim
- Co-payment — the share of each bill you pay yourself. Where to find it
- Sub-limits — caps on specific treatments or room rent. Where to find it
- Waiting periods — the time before certain conditions are covered. Where to find it
- Network hospitals, pre- and post-hospitalisation cover, and what’s excluded.
Common reasons claims get rejected
- A pre-existing condition that wasn’t disclosed when the policy was bought.
- A waiting period that hasn’t been served yet.
- A treatment the policy specifically excludes.
- Amounts above a sub-limit, or the co-payment share.
- Missing or incorrect documents.
How CoverSure helps
Upload your policy and CoverSure reads the full document to show your waiting periods, sub-limits and co-payment in plain language — before you need to claim. Our in-app advisors can guide you through the process, and CoverSure SOS is there for emergencies. You can also talk to an advisor or check what your plan covers.
Claims FAQs
What is the difference between a cashless and a reimbursement claim?
In a cashless claim the insurer settles the bill directly with a network hospital, so you pay little or nothing upfront. In a reimbursement claim you pay the hospital first and then claim the money back from the insurer with the bills and documents. Both are subject to your policy's terms — waiting periods, sub-limits and co-payment still apply.
Why do health insurance claims get rejected?
The most common reasons are a medical condition that was not disclosed when the policy was bought, a waiting period that has not yet been served, a treatment the policy excludes, or amounts above a sub-limit or co-payment. Reading these terms before you need to claim avoids most surprises.
Does a co-payment reduce how much I get back?
Yes. A co-payment means you pay a fixed percentage of each admissible claim and the insurer pays the rest. On a ₹2 lakh bill, a 20% co-payment is ₹40,000 from your own pocket.
Can CoverSure help with my claim?
CoverSure decodes your policy so you know your waiting periods, sub-limits and co-payment before you ever need to claim, and our in-app advisors can walk you through the process. CoverSure is an advisory service, not an insurer, so the claim itself is assessed and settled by your insurer.
