How to File a Reimbursement Claim with Health Insurance?

How to Raise a Reimbursement Health Insurance Claim?

Follow the steps given below to file a reimbursement health insurance claim:

Step 1: Inform the Insurance Company

First, inform your insurance company or Third Party Administrator (TPA) about your emergency or planned hospitalization. You must inform your insurer or TPA at least 48 hours before planned hospital admission and within 24 hours of an emergency hospitalization.

Step 2: Obtain Treatment

Simply obtain treatment at the hospital and focus on getting cured.

Step 3: Pay the Hospital Bill

At the time of getting discharged from the hospital, pay the entire hospital bill in full.

Step 4: Collect All Your Documents

Obtain all the documents related to your hospitalization, including the discharge summary and hospital bill, while getting discharged from the hospital.

Step 5: Fill up the Claim Form

Obtain the health insurance claim form for reimbursement and fill it out carefully and accurately. You can easily find the claim form on the website of your insurer.

Step 6: Submit All Documents to the Insurance Company

Submit the claim form and other required documents to your insurer within the stipulated time frame, which is usually 15-30 days. You can submit these documents online on the insurer's website, email them, speed post them or visit the insurer's office.

Step 7: Document Verification and Evaluation of the Claim Request

The insurance company will verify all the documents received and cross-check with the coverage available under your health insurance policy. After verification, your claim will be either accepted or rejected within 30 days of receiving the documents. If the insurer requires more documents, they will let you know.

Step 8: Settlement of Claim

If your claim has been accepted, the insurance company will pay you the claim amount.

Documents Required for Reimbursement Claim in Health Insurance

Here is a list of documents that you need to submit while filing a reimbursement claim with your health insurance policy:

• Duly filled health insurance claim form
• Copy of health card/ medical insurance policy
• Original investigation reports, like blood test reports, X-rays, CT scans, etc.
• Copy of doctor consultation papers or prescriptions or medical certificate
• Original hospital discharge summary/ day care summary
• Original hospital bills
• Original medicine bills
• Original bills for diagnostic tests
• Original bill payment receipts
• Original implant sticker/invoice
• FIR or Medico-Legal Certificate (MLC) (in case of an accident)
• Copy of KYC documents
• NEFT details

Note: If the insured person passes away during hospitalization, additional documents, such as the original death summary and a legal heir certificate, may also be required. Moreover, the exact list of claim documents may vary from one insurance company to another.

When Can You File a Reimbursement Claim with Health Insurance?

You can file a reimbursement claim with your mediclaim policy in the following circumstances:

• If you want to obtain medical treatment at a non-network hospital of your insurance company
• If you were admitted to a non-network hospital of your insurance company during a medical emergency
• If your cashless claim request is rejected by the insurance company.

Note: With cashless everywhere facility, it is possible to get cashless treatment at a non-network hospital as well.

Can Reimbursement Health Insurance Claims Be Rejected?

Yes. Reimbursement health insurance claims can sometimes be rejected for several reasons. Take a look at some of the reasons why reimbursement health insurance claims may get rejected:

• If the treatment or medical condition is not covered in your policy.
• If you do not submit all the required claim documents.
• Fraudulent claims
• Claims for treatments not advised by the doctor.
• If you hide or provide false information about a medical condition.
• If you file a claim for pre-existing diseases (PEDs) or specified illnesses before the waiting period is over.

Things to Keep in Mind While Filing a Reimbursement Claim with Health Insurance

Check out the things you should keep in mind while filing a reimbursement claim with your health insurance policy:

• Read your policy documents carefully to know what is covered and not covered under your policy.
• Check the waiting periods applicable to your policy and file a claim after the waiting period is over.
• Calculate your total medical expenses, as exceeding your coverage amount will lead to out-of-pocket expenses.
• Be prepared financially to pay the entire hospital bill, as you will get a reimbursement from your insurer after a few weeks.
• Go through the reimbursement claim process of your insurance company while buying the policy so that you do not face any hassles when filing a claim later.
• Make sure to keep a copy of all the documents submitted to your insurer, as they will need the original copies.
• Remember to renew your mediclaim policy on time, as you cannot raise a claim if your policy has expired.