Niva Bupa Claim Procedure - Explained

Health insurance claims generally follow two routes: cashless claims at a provider network and reimbursement claims when you pay for eligible treatment and later claim the covered amount from the insurer. While a Claim Settlement Ratio (CSR) of more than 90% is ideally favourable, you need to also consider other factors such as claim handling, coverage and customer support along with it. We have a CSR of 95.6% with a wide provider network and dedicated support to help make your claim journey better and seamless.

When you need to use your health insurance, knowing the claim process beforehand can make things simpler. Depending on where you receive treatment, you can either use the cashless facility or pay the hospital yourself and submit a reimbursement claim.

At Niva Bupa, we're here to help ensure your insurance claims are processed as quickly as possible. We offer cashless treatment through our provider network, where approved expenses are settled directly with the hospital. For treatment at a recognised non-network hospital, you can generally pay the expenses first and submit a reimbursement claim later within 30 days of your discharge.

What is an Insurance Claim Procedure?

The insurance claim procedure is the process of filing for a claim with an insurance company to get compensated for a loss. In terms of health insurance, this means informing the insurer about your hospitalisation or treatment, submitting the needed information and documents, and allowing your insurer to assess the claim against the policy terms.

Depending on where you receive treatment and the type of service you use, you may file a cashless claim or a reimbursement claim. Cashless claims are generally processed through provider network, while reimbursement claims involve paying the hospital or healthcare provider first and then submitting the eligible expenses to the insurer for reimbursement.

Understanding the steps to file for a claim in advance can help you know what information to keep ready and where to seek assistance when you need it.

How Does the Niva Bupa Claim Process Work?

Depending on where you receive treatment, you can either use our cashless facility or pay the hospital yourself and submit a reimbursement claim with us later on. Here's how each process works.

For Cashless Health Claims

A cashless claim lets us settle approved treatment expenses directly with the hospital, so you don't have to pay the entire eligible hospital bill upfront. You may still need to pay expenses that are not covered under your policy, such as applicable co-payments, deductibles or non-payable items. 

For planned hospitalisation, we recommend informing us at least 48 hours before the treatment. In case of emergency hospitalisation, you should intimate us within 24 hours of admission.

Here is how the cashless claim process works:

Step 1: Approach the TPA desk at any one of our Niva Bupa provider network. For planned hospitalisation, we recommend intimating us at least 48 hours before the treatment. In case of emergency hospitalisation, intimate us within 24 hours of admission.

Step 2: Share your Niva Bupa Health Card or policy number with the hospital, along with the required KYC documents and medical records.

Step 3: Now, the provider network will verify your identity for validation and submit the pre-authorisation request to us.

Step 4: After the validation is done, we review and provide our confirmation to the hospital. We ensure you are also notified of the same through SMS and email. We process the initial cashless request within 30 minutes of receiving it from the hospital.

Step 5: Once the treatment is complete, sign the required documents, including the discharge summary and final hospital bill with the detailed breakup.

Step 6: We settle the approved treatment expenses directly with the hospital, as per your policy terms and conditions and the applicable tariff agreed with the hospital. Final approval is processed within 3 hours of receiving the final discharge request.

For Reimbursement Health Claim

If you receive treatment at a recognised non-network hospital, you can pay the hospital directly and then submit a reimbursement claim to us for the eligible expenses covered under your policy. You should submit the claim within 30 days from the date of discharge. 

Reimbursement claims can be useful when cashless treatment isn't available at the hospital you choose. However, the amount we reimburse depends on your policy's coverage, limits, exclusions and other applicable terms.

Generally, the claim procedure is as follows:

Step 1: Get your treatment at any recognised hospital and settle the hospital bills directly.

Step 2: After you are discharged from the hospital, make sure you have all the relevant documents, invoices, medical reports and discharge certificate with you. We would need the originals of all the mentioned documents to process your reimbursement.

Step 3: Submit your reimbursement claim to us within 30 days from the date of discharge. You can submit the claim through the available online claim submission facility on our website www.nivabupa.com or as per your policy document. A Claim ID is generated within 24 hours of submitting the claim documents.

Step 4: Once we receive your claim documents, we review the claim based on your policy terms and conditions. We may ask for additional information or documents if required.

Step 5: Finally, we will settle the claim (as per policy terms & conditions) and reimburse the approved amount.

What Documents Do You Need for a Health Insurance Claim?

Having the right documents ready can make the claims process simpler and help us assess your claim without unnecessary delays. The documents you need can vary depending on the treatment and type of claim, but keeping your medical records, bills and policy details organised is always helpful.

Documents for Cashless Claims

For a cashless claim, the provider network (over 19000) generally coordinates with us and submits the pre-authorisation request. You may need to provide:

• Niva Bupa Health Card or policy details
• Valid KYC or identity proof
• Doctor's consultation papers and medical records
• Prescriptions and investigation reports, where applicable
• Details of the planned treatment or hospitalisation
• Any additional documents or information requested by us or the hospital

Since the hospital handles much of the cashless process, you may not need to submit every document yourself. However, keeping your medical records and identification documents ready can help the process move more smoothly.

Documents for Reimbursement Claims

For a reimbursement claim, you pay the hospital first and then submit the required documents to us. You should keep the following ready:

• Duly completed and signed claim form, where applicable
• Niva Bupa Health Card or policy details
• Final hospital bill with a detailed breakup
• Original hospital invoices and payment receipts
• Discharge summary
• Prescriptions and medical records
• Diagnostic reports and investigation reports, where relevant
• Pharmacy bills and prescriptions, where applicable
• KYC documents, where required
• Bank account details for reimbursement
• Any additional documents we request during claim assessment

We may request original physical documents if they are needed to process your claim. You should also submit your reimbursement claim within 30 days of discharge, as per the applicable process. For claims involving a high claimed amount, additional KYC requirements may apply.

Conclusion

A health insurance claim becomes much easier to manage when you already know what to expect. At Niva Bupa, we support you throughout the claims journey. Our cashless facility allows us to coordinate directly with the provider network for approved treatment expenses, while our reimbursement facility lets you claim eligible expenses after paying the hospital yourself. 

We currently have 19,000+ provider network, giving you access to cashless treatment across a wide provider network. We also process initial cashless requests within 30 minutes and final approval within 3 hours of receiving the final discharge request, subject to the applicable requirements.

Frequently Asked Questions

1. Can I claim reimbursement for treatment at a non-network hospital?

Yes, reimbursement may be available for eligible treatment at a recognised non-network hospital, subject to your policy terms. You generally pay the hospital first and then submit the required documents to your insurer.

2. How soon should a health insurance claim be intimated?

For planned hospitalisation, the claim should be intimated at least 48 hours before admission. In an emergency, intimation should be made within 24 hours of admission. 

3. How long does the cashless claim process take?

For Niva Bupa cashless claims, the initial request is processed within 30 minutes of receiving it from the hospital. Final approval is processed within 3 hours of receiving the final discharge request, subject to the policy terms and the information required to assess the claim.

4. How long do I have to submit a reimbursement claim?

A reimbursement claim should generally be submitted within 30 days from the date of discharge. Once the claim documents are submitted, a Claim ID is generated within 24 hours, helping the policyholder track the claim through the available channels.

5. Can I track the status of a Niva Bupa health insurance claim?

Yes. Claim status can be checked through the available online channels, including our website and mobile app. This also makes it easier to keep track of any additional information or documents requested during claim processing.

6. Will the entire hospital bill be covered under a health insurance claim?

Not necessarily. The amount payable depends on your policy's coverage, exclusions, limits, deductibles, co-payments and other applicable terms. Expenses that fall outside your policy coverage may need to be paid by you, even when the treatment is eligible for a claim.