How to File a Reimbursement Claim Under Health Insurance?

When Can You File a Health Insurance Reimbursement Claim?

You can file a reimbursement claim under your health insurance policy under 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 was rejected by the insurance company

Steps to File a Reimbursement Claim Under Health Insurance

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

Step 1: Intimate the Insurance Company

The first thing is to inform your insurance company or TPA about your emergency or planned hospitalization. In case you plan to get hospitalized for treatment, you must inform your insurer or TPA at least 48 hours before admission. On the other hand, if you have been admitted to a hospital due to a medical emergency, intimate your insurer or TPA within 24 hours.

Step 2: Obtain Treatment

Once you have informed your insurer, simply obtain treatment at the hospital and focus completely on getting cured.

Step 3: Pay the Hospital Bill

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

Step 4: Collect All Your Documents

Make sure to obtain all the medical documents related to your treatment at the time of getting discharged from the hospital, including the hospital bills and discharge summary.

Step 5: Fill Up the Claim Form

Once you have been discharged from the hospital, fill up the health insurance claim form of your insurance company. The form can be easily found on the website of the insurance company.

Step 6: Submit All the Documents to the Insurance Company

You should submit all the required documents to your insurance company within the stipulated time frame (usually 15-30 days). You can check your policy documents or contact your insurer to know the exact list of documents required.

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. Once the documents have been verified, 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: Payment of Claim Amount

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

Documents Required to File a Reimbursement Claim Under Health Insurance

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

Duly filled health insurance claim form
Copy of health card/ insurance policy
Original investigation reports like blood test reports, X-rays, CT scans, etc.
Copy of doctor consultation papers or prescriptions
Original hospital discharge summary/ day care summary
Original hospital bills
Original medicine bills
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

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

Check out a few things that you should keep in mind while filing a health insurance reimbursement claim:

Read your policy documents carefully and know what is covered and not covered under your policy.
Go through the claim process of your insurance company while buying the policy so that you do not face any hassles at the time of filing the claim.
Make sure to keep a copy of all the documents that you submit to your insurer as you will have to submit the original copy.
Check the waiting periods applicable under your policy and file a claim after the waiting period is over.
Remember to renew your health policy on time as you cannot raise a claim if your policy has expired.

Summing It Up

Filing a claim is the first step to obtaining financial assistance from your insurance company at the time of a medical emergency. If you cannot file a cashless claim, a reimbursement claim is the best option for you. Make sure to carefully go through the steps involved in filing a reimbursement claim so that you make no mistakes. Also, keep the above-mentioned things in mind while filing a reimbursement claim under your health insurance policy.