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Raheja QBE Health Insurance Claim Settlement

Today’s health insurance buyers are smart, suave, savvy and discerning. They are well acquainted with how health insurance works and choose an insurance company based on certain well researched parameters over and above the benefits offered by the insurer. Health insurance buyers want to know how large a network of hospitals they will have cashless access to and they want to know about the insurer’s track record. 

What is a claim settlement ratio and why you must assess it: 

The insurer’s track record is assessed by viewing its claim settlement ratio. Policyholders differ in their stance of what ratio is preferable, however. Some policyholders prefer a higher than average ratio, especially for short term policies because they prefer to go with a company that shows a higher possibility of approving their claims. Others want a moderate or average claim settlement ratio, particularly when they are opting for a long policy term because they want the insurer to be profitable and stay in business till the day they make a claim. As a health insurance buyer, what you need to know is this: every health insurance company receives its share of bogus and invalid claims, so some amount of rejections is healthy and necessary. 

Raheja QBE Health Insurance USPs:

Raheja QBE has a claim settlement ratio of 96% according to its website, up from about 83% a few years ago. Of course, insurance companies across the board are increasingly concerned with maintaining a favourable claim settlement ratio because just as you are doing right now, policy buyers can just whip out their smartphones and quickly conduct a background check on them. 

Another thing that Raheja QBE Health Insurance has going for it is its network of 5000 hospitals. That means that policyholders have 5000 options when it comes to obtaining cashless hospitalization. Of course, a reimbursement claim can be made after hospitalisation at any hospitalization in the country

Raheja QBE Cashless hospitalization claim

  1. Visit a network hospital
  2. Every empaneled hospital compulsorily has what is known as a TPA department. Get hold of an official from the TPA department
  3. The official will give you a form that you must fill out 
  4. Then the TPA department will coordinate with Raheja QBE Health Insurance to get a pre-authorization

It is important for policyholders to understand that TPA departments are not necessarily 24×7 like the hospital. Like labs and accounting, the TPA department had working hours and working days. If you are hospitalized outside of the working hours, you might have to go for a reimbursement claim instead. 

The same is true if your pre authorisation is not approved due to insufficient details availability prior to hospitalization. 

Do not stress and worsen your health condition in either situation – you can still make a reimbursement claim once discharged. Relax and have trust in your insurer. Why must you worry when you have a valid claim and Raheja QBE has a claim settlement ratio of 96%? 

Raheja QBE reimbursement claim 

  1. Try and intimate the insurer 48 hours prior to hospitalization if you do have time in hand 
  1. Get admitted at a network of non network hospital as per your convenience
  1. Maintain originals of
  • All bills and receipts
  • All x-rays, ECG, sonography, CT, scan, MRI, Covid-19 tests, blood tests and any other diagnostic tests
  • Doctor’s prescriptions 
  • Doctor’s diagnosis and treatment certificates and paperwork with hospital letterheads and/or stamp 
  • Surgery certificate and details from doctor if any 
  • Hospital discharge form 

Keep copies of anything you might need to refer to later as you need to submit all originals with your application. 

  1. Fill up, sign and submit insurance paperwork 

Documentation guidelines

When you make a cashless claim, you have a relatively lower amount of documentation to be completed since the hospital, not you, carries out the coordination with the insurance company. However you still need to approach the hospital’s insurance coordination folk with your health card ID. And you will also need to fill up a form there and prove your identity. 

The documents list for a reimbursement claim is typically longer and that’s one of the other reasons why policyholders show a clear preference for cashless claims. For a Raheja QBE health insurance reimbursement claim settlement, you need: 

  1. The claim form, completed and signed 
  2. Prescriptions and receipts for all medicines
  3. Bills and receipts for doctor and consultation
  4. Bills and receipts for hospitalisation
  5. Bills and receipts for surgery and/or treatment 
  6. Certificate of diagnosis and surgery if any 

Do note that other documents might be requested by the insurer. Hold on to originals of everything not submitted until your claim amount comes through to your bank account.


Should I try to keep my hospitalisation less than 1 day to keep spending at the minimum and get my health insurance claim approved?

Health insurance companies, including Raheja QBE Health Insurance accept hospitalization claims for policyholders who have been admitted for a minimum of 24 hours.

Should I look for a company that boasts a 100% claim settlement ratio?

No, because such a company will run out of funds very quickly. At least a few claims need to be rejected for the insurer to stay in business. If the insurer had to shut down due to irretrievable losses, you will not receive your claim.

Claim ratio is never 100%, but when it comes to an EMI health card I can use it for any and every health expense, even hair transplant. Is it not better?

It is true that there are little or no exclusions when it comes to healthcare expenses you can pay for using your health card. However you still pay for your own expenses; it is just that you get more time to pay. It is like having a loan to pay for your healthcare.
However a health insurance policy pays for your healthcare in a health emergency. Obviously since your bill is being paid off by the insurer, the guidelines and inclusions will be tighter.

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