Question 1

What is the difference between cashless and reimbursement claims?

Accepted Answer

Cashless claims involve the hospital billing the insurer directly, at network hospitals only — you pay little to nothing upfront. Reimbursement claims involve you paying the hospital first, then submitting bills to the insurer for repayment, usable at any hospital.

Question 2

Why do insurers reject claims?

Accepted Answer

Common reasons include non-disclosure of pre-existing conditions at policy purchase, claims during the waiting period, treatment for excluded conditions, or incomplete documentation. Accurate medical history disclosure at purchase significantly reduces rejection risk.

Question 3

What is a waiting period, and how does it affect claims?

Accepted Answer

A waiting period is the time after policy purchase during which certain conditions aren't covered — typically 30 days for illness (except accidents), 1-4 years for pre-existing diseases, and 2 years for specific conditions like cataracts or hernia.

Question 4

Can I file a claim for a family member covered under my family floater?

Accepted Answer

Yes, any member covered under the floater can raise a claim against the shared sum insured — just ensure the claim form identifies the correct patient.

Question 5

What is a co-payment clause?

Accepted Answer

A co-payment clause requires you to pay a fixed percentage of the claim amount yourself, common in senior citizen plans or certain corporate policies. It's disclosed in your policy document — ask us to check yours if you're unsure.

Question 6

How do I appeal a rejected or partially approved claim?

Accepted Answer

You can request a re-review from the insurer with additional documentation or clarification. Our claims desk can help draft the appeal and follow up directly with the insurer or TPA.

Question 7

Does TruCover365 process my claim, or does the insurer?

Accepted Answer

The insurer makes the final approval and payment decision — TruCover365's claims desk assists with documentation, hospital coordination, and following up on your behalf throughout the process.

Question 8

What is a TPA and how are they involved in claims?

Accepted Answer

A TPA (Third Party Administrator) is an entity insurers appoint to process claims and coordinate with hospitals on their behalf. Not all insurers use a TPA — some process claims in-house.

Health Insurance Claims FAQ

All Claims Questions

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