How to Raise a Reimbursement Claim on Health Insurance?

Posted on: Dec 12, 2023 | | Written by:

How to Raise a Reimbursement Claim on Health Insurance?

Publication date: December 12, 2023. EST READ TIME: 3 MIN

Thanks to medical inflation and the increasing incidence of health conditions, healthcare costs are rising steeply throughout the country. However, if you have health insurance, you can opt for quality treatment at any network or non-network hospital without worrying about the bills. All you must do is notify the insurance company about your hospitalisation and submit your claim within the stipulated time. The insurer will cover the bills up to the sum insured by your health plan and save you from financial setbacks.

There are two forms of health insurance claims – cashless and reimbursement. While cashless claims are quick and hassle-free, reimbursement claim filing and processing take more time. Let’s understand medical claim reimbursement in detail.

Modes of claim settlement process in health insurance

There are two modes of claim settlement processes in health insurance – cashless and reimbursement.

1. Cashless claim:

If you choose a network hospital for a medical procedure, you can file a cashless claim with the insurance provider. You must show your cashless card at the hospital and submit a duly filled claim form at the TPA desk. The insurer will coordinate with the hospital and settle your claim.

2. Reimbursement claim:

You can also choose a non-network hospital for a medical procedure and claim reimbursement for the expenditures. For this, you must settle the hospital bills from your pocket at the time of discharge and then file a reimbursement claim with the insurance provider.

How does the type of claim affect the policyholder?

The following table will tell you how the type of claim affects the policyholder:

Parameters	Cashless Claims	Reimbursement Claims
Claim settlement process	If you choose a network hospital and file a cashless claim, the insurer settles your medical bills directly with your chosen hospital.	For a reimbursement claim, you must settle the bills from your pocket and then claim reimbursement for the expenses.
Required documents	Cashless claims require minimum documents, i.e., your cashless card and the claim form. The network hospital will share your bills with the insurance company.	You must collect all original bills and receipts and submit them to the insurance provider along with the reimbursement claim form.
Claim settlement duration	Cashless claims are settled faster.	Reimbursement claims processing and settlement take longer than cashless claims.

Steps to raise a reimbursement claim in health insurance

The following are the steps to raise a health insurance reimbursement claim:

Step 1: Notify the Insurance Company

Before you raise a reimbursement claim, you must inform the insurance company about your hospitalisation. If it is a planned hospitalisation, notify the insurer at least 48 to 72 hours in advance. In case of a medical emergency, inform them within 24 hours of hospitalisation.

Step 2: Register Your Claim

After getting discharged from the hospital, register your claim within the stipulated period. Most insurance companies want policyholders to submit reimbursement claims within 7 to 15 days of being discharged from the hospital. You can register your claim online/offline.

To register your claim, fill out the reimbursement claim form and submit it to the insurance provider/TPA along with the following documents:

• Photocopy of a valid ID card (PAN Card/ Adhaar Card/ Passport/ Driving licence)

• Original discharge summary

• Doctor’s consultation slips and prescriptions

• Doctor’s prescriptions recommending diagnostic tests and hospitalisation

• Original prescriptions for medicines

• Original pharmacy bills

• Diagnostic reports of blood tests, X-rays, etc.

• Any other receipts from the hospital

• Ambulance receipt, if applicable

• FIR, in case of an accident

• Cancelled cheque of your bank account

Since you must submit the original documents to the TPA or insurer, make sure you take their photocopies for your records.

Step 3: Claim Verification

Once you submit your health insurance reimbursement claim, the insurer will verify the same. If they require any additional documents, they may communicate with you through call, email or SMS.

Step 4: Claim Settlement

If everything looks fine, the insurer will approve your claim and reimburse the claim amount to your bank account within 3-4 weeks. The insurer may process your claim partially or fully, as per the policy terms and conditions.

Conclusion

With the option to file a reimbursement claim, you can choose any non-network hospital for a medical procedure without worrying about the expenses. However, make sure you collect all your hospital bills and receipts and submit these to the insurance provider along with the claim form. Also, file medical claim reimbursement within 7 to 15 days of getting discharged from the hospital to avoid claim rejection.

Disclaimer: The above information is for illustrative purposes only. For more details, please refer to the policy wordings and prospectus before concluding the sales.

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