Reimbursement claim in health insurance is the mechanism to pay back to the policyholderA person who pays a premium to an insurance company in exchange for the insurance protection provided by a policy the expenses that have been incurred on treatment. This treatment needs to be covered as per the policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy terms.
The process for reimbursement of a health insurance claim needs to follow a well defined process laid down by the regulator as well as by the specific insurance company.
A health insurance reimbursement claim can be either for the following –
- Main Hospitalisation
- Pre and Post Hospitalisation
How is a reimbursement health insurance claim settled?
A reimbursement health insurance claim is settled by the following steps:
- Pay for medical expenses: The policyholderA person who pays a premium to an insurance company in exchange for the insurance protection provided by a policy pays for medical expenses out of pocket at the time of treatment or hospitalization.
- Collect receipts and bills: The policyholderA person who pays a premium to an insurance company in exchange for the insurance protection provided by a policy collects all receipts, bills, and medical reports related to the treatment or hospitalization.
- Submit claim: The policyholderA person who pays a premium to an insurance company in exchange for the insurance protection provided by a policy or healthcare provider submits a claim to the insurance company detailing the medical expenses incurred. The claim should include all relevant information such as date of service, name of the healthcare provider, and the amount of expenses.
- Verification of coverage: The insurance company reviews the claim to verify that the expenses are covered under the policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy. The insurance company may also verify that the policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy is active and that the policyholderA person who pays a premium to an insurance company in exchange for the insurance protection provided by a policy has fulfilled any requirements, such as meeting a deductible.
- Payment of claim: If the expenses are covered, the insurance company pays the claim to the policyholderA person who pays a premium to an insurance company in exchange for the insurance protection provided by a policy. The payment is made either by cheque or directly deposited into the policyholder’s bank account.
- Appeal process: If the policyholderA person who pays a premium to an insurance company in exchange for the insurance protection provided by a policy or healthcare provider believes that the claim has been denied unfairly, they can initiate an appeal process. The insurance company will review the appeal and may either approve or deny the claim. If the appeal is approved, the policyholderA person who pays a premium to an insurance company in exchange for the insurance protection provided by a policy or healthcare provider will receive payment for the covered expenses.
It is important to note that the exact process of settling a reimbursement health insurance claim may vary depending on the insurance company and the type of policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy. Policyholders should familiarize themselves with the terms of their policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy and the procedures for submitting and settling a claim.
What factors can affect the reimbursement process?
The reimbursement claim process can be complicated, and policyholders should familiarize themselves with their insurance policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy to understand what is covered and what is not.
There are several factors that can affect the reimbursement process in health insurance, including:
- PolicyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy Terms: Does your policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy cover the costs for which you have been treated? To what extent are they covered? For example, are there any capping in the terms of the health insurance policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy which do not allow for the entire amount to be paid.
- Network of healthcare providers: Some insurance policies may only cover medical expenses incurred within a specific network of healthcare providers. This is especially true in case of ‘blacklisted’ hospitals. Even if the terms of the policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy are covering your expenses, just in case unknowingly you go to one of the hospitals blacklisted by the insurer, the insurance company may not cover the charges.
- Medical expenses incurred: The type and amount of medical expenses incurred can affect the reimbursement process. Some insurance policies may not cover certain types of expenses, such as elective procedures or alternative therapies ( unproven treatments). Additionally please note the list of non-medical expenses which are standardised by the regulator and are not covered under the policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy.
- Deadlines for submitting claims: Insurance companies may have deadlines for submitting claims. If a policyholderA person who pays a premium to an insurance company in exchange for the insurance protection provided by a policy misses the deadline, they may not be eligible for reimbursement. For example, most of the polices say that the claim needs to be submitted within 30 days of discharge in case of main hospitalisation. For pre and post hospitalization claims, it needs to be typically submitted within 30 days of the time limit of the post hospitalization claim or within 7 days of the ‘last treatment’ taken.
- Accurate documentation: Accurate and complete documentation is critical for the reimbursement process. Policyholders and healthcare providers must provide all necessary information and documentation to the insurance company to ensure that the claim is processed correctly. Any delay in providing a complete and accurate set of documents will delay the settlement of the claim. In extreme cases, such delays can also result in closure of claim files as non-payable.
- Claim denial: If the insurance company denies a claim, the policyholderA person who pays a premium to an insurance company in exchange for the insurance protection provided by a policy or healthcare provider can initiate an appeal process.
What are the documents required for a reimbursement claim?
The documents required for a reimbursement health insurance claim typically include:
1. Copy of Hospital Registration Certificate with Registration number and number of beds certificate (Please note the hospital should be minimum of 15 inpatient beds for a mediclaim. This may not be required in case of larger hospital which are well known and in larger towns / cities ).
2. Claim Form duly signed. This is absolutely mandatory .
3. Copy of the Claim Intimation, if any ( If you are filing the main hospitalization expenses for reimbursement, then you would have done the intimation of the claim in advance, as per your policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy terms. Do attach a copy of that).
4. Hospital Main Bill with proper breakup of the expenses. Often there is a summary bill and then there is a bill which mentions all line item wise expenses. The insurer will need the detailed latter bill
5. Hospital Bill Payment Receipt for which the policyholderA person who pays a premium to an insurance company in exchange for the insurance protection provided by a policy / claimant made the payment to the hospital. Do note that this receipt will need to be numbered.
6. Original Hospital Discharge Summary (which should clearly mention –
- Patient name
- Date of Admission
- Date of Discharge
- Age of the Patient
- Final Diagnosis
- GPLA status in case of pregnancy related claim.
- Case Summary / History (On Examination), Course in Hospital, Line of Treatment, Advice at Discharge with signatures and stamp of treating doctor. This will be on the hospitals letter head
7. Others medical document that may be provided
8. Doctor’s Prescriptions. Often in non-emergency cases, the patient is first shown to the doctor n OPD basis, In such cases all doctors prescriptions will be needed
9. Self attested ID and address proof of patient and employee.
10. Self attested PAN card copy of the employee.
11. Pharmacy bills.
12. MLC Report & Police FIR, Alcoholic declaration in case of accidental cases particularly Road Traffic AccidentAny Unforeseen and unanticipated event is considered an accident. (RTA)
13. Also in RTA Cases, detailed circumstances of the trauma with date, place and time. This is mandatory for reimbursement claim in case of an accidentAny Unforeseen and unanticipated event is considered an accident. case.
14. Implant Invoice and sticker if any.
15. All Investigation Films and Reports – ECG / CT / MR / USG / HPE or any other investigation reports. Obviously there will be no films in cases of blood investigations, urine / stool investigations or biopsy
16. Original cancelled cheque with primary insured printed name, for the transfer of payment to your bank account. If you providing cancel cheque without printed name, please submit the copy of bank statement. If you don’t have cancel cheque , than provide a bank attested passbook copy/statement copy(Computer generated signature not accepted) .
Important points to remember
- All documents to be filed under the claim have to be in originals
- Once the claim form is filled you need to submit the claim form along with all mandatory documents.
- Following original documents are mandatory to process a claim under reimbursements
- Please note the hospital should have a minimum of 15 beds.
Detailed description of the documents that needs to be provided:
Please read the claim form carefully before you start filling the claim-
The following fields are mandatory in a claim form
- PolicyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy number (in case of Corporate policies, even if you don’t have the policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy number, that’s fine, you can omit it
- Cashless identity card number ( would be mentioned on your hard copy or e-card in case you have that)
- Name of the insured ( Primary Member) with address and contact details
- Name of the corporate and employee code
- Name of the patient, date of birth and relationship with the employee
- Tick on the type of claim, writeTo insure, underwrite, or accept an application for insurance., and date of admission and discharge, name, address and contact details of the hospital
- Provide the details of illness / injury / disease
- Provide the details of amount that is being claimed with breakup of bill numbers
- All documents in original
- Signature of the claimant along with place and date (this is mandatory)
There are times when the TPA may request to provide additional information when there is any shortfall / query in the documents submitted by you. Such could be either to ascertain / confirm that the treatment is aligned to the coverage under your health insurance cover or they may request for some cost breakup details, etc. These unforeseen and relatively few interventions, may delay the processing of your claim which will further delay the payment. Hence, you need to immediately furnish the documents requested by the Insurer / TPA to ensure speedy processing of your claim.
Do note there are some non-payable items which the Insurance Company will not be paying as a part of the health insurance claim. These are generally for the test of HIV, consumable items such as syringe, gloves.
Exhaustive guide to claim intimation in group health insurance (Do note, this is an Important Clause )
You should intimate the TPA within 24 hours of hospitalisation in case of unplanned / emergency cases and before 48 hours of hospitalisation in case of planned treatments. This will be applicable for both cashless as well as reimbursement cases. This clause allows an insurer to depute an investigator, if they so wish.
What is the difference between cashless and reimbursement claim?
Below is a concise comparison table that highlights the significant difference between the two primary types of health insurance claims: cashless and reimbursement.
| Basis | Cashless claim | Reimbursement claim |
| Payment | The insurance company pays the medical bills directly to the hospital | You pay for the medical expenses and later claim reimbursement from the insurance company. |
| Process | You need to inform the insurance company and the hospital before hospitalization, and the hospital sends a pre-authorization request to the insurance company. | You need to keep all the bills and receipts and submit a claim to the insurance company after discharge. |
| Time | The cashless process is faster, as the hospital bills are settled directly by the insurance company. | You need to pay the bills first and then wait for the insurance company to reimburse the expenses. |
| Network Hospitals | The cashless process is only available at network hospitals of the insurance company. | Reimbursement process can be availed at any hospital subject to terms ( should not be blacklisted, should meet the minimum criteria for being called a hospital i.e. number of beds, ICU, trained staff etc) |
In conclusion, reimbursement is a critical aspect of the healthcare insurance ecosystem that helps to cover the cost of medical care for policyholders.
In case you need any support, feel free to reach out to our expert team who will help you navigate this process.
Please get in touch with us at any stage of your hospitalisation requirements.
While our endeavour is to ensure that you are not inconvenienced on any count. Our role is to ensure that your case is presented accurately with the insurer / TPA and no delays or rejections occur unjustly. At PlanCover.com, we represent your interests above all else. Our commitment and actions are aligned to ensuring that the process is smooth for you.
