How to Raise a Health Insurance Claim for Planned Hospitalisation

Planned hospitalisation sounds a bit odd, right? After all, we usually associate hospital visits with emergencies. But there are plenty of situations where you know in advance that you’ll need medical care like a scheduled surgery, maternity delivery, or a recommended treatment for a long-term condition.

If you have health insurance, it’s smart to use it for planned hospitalisation. But here’s the thing: you need to follow the right steps to ensure your claim is approved. Miss a step, and you might face delays or even a rejection.

Let’s walk through the health insurance claim process for planned hospitalisation.

What Counts as Planned Hospitalisation?

Planned hospitalisation is any medical procedure or treatment that:

• Isn’t an emergency
• Has been scheduled in advance by your doctor
• Gives you time to inform your insurer and get pre-approval

Examples include:

• Knee replacement surgery
• Cataract surgery
• Maternity-related admissions
• Chemotherapy sessions
• Hernia operations
• Dental surgeries (if covered)

In short, if you have time to plan, you also have time to prep your insurance paperwork.

Step-by-Step: How to Raise a Claim for Planned Hospitalisation

Here’s what you need to do to raise a successful health insurance claim:

1. Inform Your Insurer in Advance

Most insurance companies require you to inform them at least 3–5 days before the date of admission. You can usually do this through:

• The insurer’s mobile app
• Their website
• Customer care number
• Visiting a branch or TPA desk (Third Party Administrator)

This step is crucial. Missing this notification window can cause unnecessary delays or rejections.

2. Choose a Network Hospital

Always check if the hospital is in your insurance provider’s network list. If it is, you can go for cashless treatment, which means the insurer directly settles the bill with the hospital.

If it’s a non-network hospital, you’ll have to go for reimbursement meaning you pay first and claim the money back later.

3. Fill Out the Pre-Authorisation Form

At a network hospital, ask for a pre-authorisation request form at the insurance desk. You’ll need:

• Policyholder details
• Patient details
• Diagnosis and treatment plan (filled by your doctor)
• Expected date of admission
• Estimated cost

Submit this form to the hospital’s insurance help desk and they will forward it to your insurer.

4. Wait for Approval

Once your insurer receives the pre-authorisation request, they’ll review:

• Your policy coverage
• Any waiting periods or exclusions
• Sum insured and balance limits
• Documentation completeness

If everything checks out, you’ll receive a cashless approval letter, often within 24–48 hours.

5. Admission and Treatment

Once approved, you can get admitted as planned. The hospital will keep the insurer in the loop about the treatment progress.

Make sure to:

• Carry your health card and ID proof
• Sign all necessary forms
• Keep a personal file with copies of all records

6. Discharge and Final Settlement

Before discharge, the hospital will send the final bill to the insurer for approval. If everything is within policy limits, the insurer clears the payment directly.

If there are non-payable items (like personal use items, food charges, etc.), the hospital may ask you to pay that portion.

7. Reimbursement (If Not Cashless)

If you couldn’t get cashless treatment (say, the hospital wasn’t in-network or the pre-approval didn’t come through in time), you can still raise a reimbursement claim.

Here’s what you’ll need after discharge:

• Claim form (filled and signed)
• Hospital bills and receipts
• Discharge summary
• Doctor’s prescription and reports
• Diagnostic and pharmacy bills
• Insurance card copy and KYC documents

Submit all this to your insurer within 7–15 days of discharge (depending on their timeline).

Common Mistakes to Avoid

• Waiting until the last minute to inform your insurer
• Choosing a non-network hospital without checking
• Incomplete or incorrect forms
• Ignoring exclusions or waiting periods in your policy
• Misplacing original bills (they’re often mandatory for reimbursement)

Even small mistakes can delay or derail your health insurance claim, so double-check everything before submitting.

What If Your Claim Gets Rejected?

Sometimes, even planned hospitalisation claims get rejected due to paperwork issues, policy exclusions, or technicalities. It’s frustrating, especially after planning everything so carefully. That’s where Insurance Samadhan can help. If your insurance claim has been unfairly denied, they can:

• Analyse your policy to check if the rejection is valid
• Review documentation and rejection reasons
• Draft a strong appeal letter to your insurer 
• Guide you through the appeal or grievance process, right up to the Ombudsman if needed

They take the stress off your plate so you can focus on recovery not paperwork.

Final Thoughts

Raising a claim for planned hospitalisation is smoother when you know the process. Whether you’re getting surgery or preparing for a baby, your health insurance is there to support you but only if you follow the right steps.

Plan early, stay organised, and keep your insurer in the loop. And if you ever hit a snag, Insurance Samadhan is ready to back you up and make sure you get the coverage you’ve paid for.