How Do Insurers Verify Repeated Hospitalisations?

Health insurers in India verify repeated hospitalisations by reviewing medical records for treatment necessity, utilising a field healthcare specialist to verify patient status, and checking the 24-hour inpatient care requirement. They scrutinise for policy exclusions, pre-existing conditions, and potential fraudulent patterns, usually requiring detailed documentation to ensure claims are not for the same illness.

Verification Process Involved for Repeated Claims

• Medical Necessity Review:Your insurance provider’s medical team sructinise all submitted documents to determine if each hospitalisation was necessary and not an extension of a previous, already treated condition.


• Field Doctors: A field doctor empanelled with your insurer may be allocated to visit the hospital to verify the patient's condition and whether the treatment is deemed necessary.


• 24-Hour Rule: The insurer confirms the hospital is certified and that the patient stayed for a minimum of 24 hours under inpatient care.


• Review of Previous Claims:They check if the repeated hospitalisation is for the same illness, which might be excluded if it fails to meet the "restoration of sum insured" criteria.


• Documentation Check: Accurate and detailed documentation, which involves admission notes and doctor reports, is crucial, as a lack of evidence can lead to claim rejection or denial during medical emergencies.


• Network Hospital Verification:For cashless claims, they instantly check if the empanelled network hospital has followed the required administrative protocols.

Key Consideration

• How often can you claim? You can raise a claim as many times as required, provided the sum insured is not exceeded.


• Restoration Advantage: Leading insurers in India offer automatic restoration of the sum insured, permitting you to make multiple claims during a policy year.


• Pre-existing diseases: If the hospitalisation is associated with a pre-existing condition, the policyholder must have completed the outlined in the policy.

Reimbursement Timeline: In the reimbursement cases, claims should be submitted within the mentioned time period.