Reimbursement Claims in Health Insurance

What is a Reimbursement Claim in Health Insurance?

A reimbursement claim in health insurance refers to a process where the policyholder initially pays the hospital bills and later submits a claim to the insurance provider for reimbursement. To receive the paid medical expenses, the insured must provide all necessary documents to the insurer, including hospital bills, prescriptions, medical reports, and payment receipts, as proof of expenditure. The insurance company then reviews the claim, verifies the submitted documents, and processes the reimbursement.

Unlike a cashless claim, where the insurer directly settles the medical bills with the hospital, a reimbursement claim requires the policyholder to manage the payments upfront before seeking a reimbursement. Moreover, health insurance companies usually take up to 30 days to settle reimbursement claims.

When Should a Reimbursement Claim Be Filed in Health Insurance?

A reimbursement claim under a health insurance policy should be considered in the following situations:

• When the insurance provider denies a cashless claim request
• When the policyholder or their family fails to notify the insurer about hospitalisation within the deadline
• When there is a medical emergency and the treatment needs to be get done as earliest as possible.

How to Initiate a Reimbursement Claim in Health Insurance?

Here are the steps to follow to initiate a reimbursement claim in mediclaim insurance:

Step 1: The policyholder must notify the insurance company or Third Party Administrator (TPA) about the planned hospitalisation at least 48 hours in advance and within 24 hours in case of emergency.

Step 2: The insured should proceed with the necessary medical treatment at the hospital.

Step 3: Before discharge, the policyholder is required to pay the total hospital bill.

Step 4: All relevant medical documents, including the discharge summary, hospital bills, prescriptions, and diagnostic reports, should be collected at the time of discharge.

Step 5: The insured must complete the health insurance claim form accurately which is available on the insurer's official website.

Step 6: The completed claim form, along with all necessary medical documents, should be submitted to the insurance provider within 30 days.

Step 7: The insurance company will review the submitted documents. Once the verification is complete, the claim will either be approved or rejected within 30 days.

Step 8: If the claim is approved, the insurance company will reimburse the approved amount directly to the policyholder's account.

Related Resources: How to File a Reimbursement Claim Under Health Insurance?

Documents Required for a Reimbursement Health Insurance Claim

When applying for a reimbursement claim under a mediclaim insurance policy, policyholders need to submit the following documents:

• Accurately filled claim form
• A copy of your health card or insurance policy
• Original test reports such as blood tests, X-rays, CT scans, etc.
• Original hospital discharge or day-care summary
• Copy of doctor's consultation notes or prescriptions
• Original medicine bills and receipts
• Original hospital bills
• Receipts for all payments made towards medical expenses
• Original implant invoice or sticker
• A copy of KYC documents
• FIR or Medico-Legal Certificate (MLC), in case of accident
• NEFT details
• Original death summary and a legal heir certificate (if the policyholder dies during hospitalisation)

Why is Reimbursement Claim Rejected in Health Insurance?

Here are a few reasons why reimbursement claims can be rejected in health insurance:

1. Incomplete Documentation

   One of the most common reasons for reimbursement claim rejection is missing or incorrect documentation. If any of the required documents are missing, unclear, or contain errors, the claim may not be approved.

2. Waiting Period

   Most health insurance policies have a waiting period for certain illnesses, especially pre-existing diseases, critical illnesses, etc. If a claim is filed during this waiting period, the insurer will reject it.

3. Non-Disclosure of Pre-Existing Diseases (PEDs)

   If the insured does not disclose his/her PEDs when buying the mediclaim policy, the insurer may reject any claims related to those conditions.

4. Claim for Excluded Treatments

   Every mediclaim insurance policy has certain exclusions that may not be included in the policy coverage. If a person submits a claim for a treatment that falls under the exclusion list, the insurer will reject it.

5. Policy Lapse

   If the policyholder forgets to renew the policy on time and the policy lapses, any claims made during the lapse period will be automatically rejected.

6. Exceeding Sum Insured Limit

   Every health insurance policy has a fixed sum insured, which is the maximum amount that can be claimed in a policy year. If a person's medical expenses exceed this limit, the insurer will only reimburse up to the sum insured, and the rest must be paid out of pocket.

7. Delay in Filing the Claim

   Insurance companies have specific deadlines for submitting reimbursement claims. If a person fails to file a claim within the stipulated time, it may be rejected.

You May Also Read: 10 Reasons Why Your Health Insurance Claim Can Get Rejected

What to Do if a Reimbursement Claim is Rejected?

If a health insurance reimbursement claim is denied, the policyholder can take the following steps to address the issue:

• Review the Reason for Rejection- The policyholder should carefully examine the insurer's rejection letter or explanation to understand the specific reason for reimbursement denial.
• Check Policy Terms and Conditions- It is essential for the insured to check whether the requested health insurance claim adheres to all the terms and conditions outlined in the policy document.
• Correct Documentation Errors- The policyholder must ensure that all submitted documents, including hospital bills, prescriptions, and discharge summaries, are accurate and complete.
• Submit an Appeal- If the rejection is unjustified, the policyholder can formally appeal the decision by providing additional supporting documents and clarifications.
• Seek Further Assistance- If the issue remains unresolved, the policyholder can contact the insurer's grievance redressal team for further review.

Learn More: What to Do if Your Health Insurance Claim is Denied?

What to Keep in Mind While Opting for Reimbursement Claim in Health Insurance?

When submitting a reimbursement claim, policyholders should keep the following points in mind to ensure a smooth claim process:

• Policyholders should be aware of the insurer's reimbursement process, including submission deadlines and required documents.
• All necessary documents should be gathered at the time of discharge, including hospital bills, prescriptions, and discharge summaries.
• Policyholders should follow up with the insurer to check the claim status and provide additional information if required.
• It is essential to understand sub-limits, deductibles, and exclusions in the mediclaim policy to prevent unexpected claim rejection.
• The insured must be transparent about the PED, if any, at the time of buying the policy.
• Correct bank details must be provided to ensure seamless reimbursement of the approved claim amount.