Claim

A claim is a formal request you or your healthcare provider submit to your insurance company to receive reimbursement or direct payment for eligible medical or dental expenses covered under your plan. Submitting a claim provides the insurer with the necessary information - such as receipts, treatment details, and provider information - to verify the service and determine the amount payable according to your policy’s terms.

Claims can be submitted electronically by the provider through a direct billing system, or manually by the plan member using an online portal, mobile app, or paper claim form. Most modern health and dental plans support electronic submission, which speeds up processing and reduces the need for manual paperwork. Once a claim is approved, the insurer either reimburses you directly or pays the provider on your behalf, depending on how the plan is set up.

Each claim is assessed based on eligibility, remaining maximums, coinsurance, deductibles, and any applicable exclusions or limitations.

Example:

If you visit a physiotherapist and pay $100 for treatment, you can submit a claim through your insurer’s app with a photo of the receipt. If your plan covers 80 percent, the insurer reimburses $80 directly to your bank account.

What to Watch For:

Always submit claims within your insurer’s time limit, which is usually 12 to 18 months from the date of service. Keep original receipts in case additional documentation is requested. Check that your provider’s name, license number, and service date are clearly listed to prevent delays or denials.