How to Successfully Claim Health Insurance Reimbursement?

At a Glance

• What Is a Health Insurance Reimbursement Claim? – Understanding how reimbursement claims work and when they apply.
   
• Major Benefits of Claiming Reimbursement – Key advantages like flexibility in hospital selection and coverage for all eligible expenses.
   
• How to Submit a Health Insurance Reimbursement Claim? – Step-by-step guide on filing a claim, from informing the insurer to receiving reimbursement.
   
• Common Reasons for Claim Rejection – Factors that can lead to claim denials, such as missing documents, policy exclusions, and late submissions.
   
• What to Do If Your Claim Is Rejected? – Steps to take, including resubmitting documents, filing an appeal, and approaching the Insurance Ombudsman.

Filing a health insurance reimbursement claim can feel overwhelming. You’ve already dealt with a medical emergency, and now there’s paperwork, approvals, and waiting involved. The process may seem complicated, but it doesn’t have to be.  

With the right steps, you can avoid delays and claim the reimbursement smoothly. Knowing what documents to submit and how to follow up can make the process faster and hassle-free. Here’s everything you need to know about successfully claiming health insurance reimbursement.

What Is a Health Insurance Reimbursement Claim?

A reimbursement claim is when you pay for medical treatment out of pocket and later request compensation from your insurer. Unlike cashless claims, where the insurer settles the bill directly with the hospital, you need to submit documents to prove your expenses.

This type of claim is common when:

• You get treated at a hospital that is not in the insurer’s network.
   
• You could not get pre-approval for a cashless claim.
   
• Your insurer requires you to pay first and claim later.

Benefits You Get While You Claim the Reimbursement 

Reimbursement insurance offers flexibility and financial support when dealing with hospital expenses. Here’s why claiming the reimbursement through this process is beneficial:

1. Freedom to Choose Any Hospital

Unlike cashless claims that require you to visit network hospitals, reimbursement allows treatment at any hospital of your choice. This is especially useful in emergencies or when your preferred doctor is in a non-network hospital.

Read More: Top 10 Claim Settlement Ratio Health Insurance Companies in India

2. No Dependence on Network Hospitals

If a hospital is not tied up with your insurer, you can still avail of medical care and later claim the reimbursement. This ensures you don’t compromise on treatment quality.

3. Time to Arrange Documents

Since reimbursement claims allow you to submit documents after discharge, you have time to collect all necessary bills and reports without rushing. This helps in ensuring a complete and error-free submission.

4. Coverage for All Eligible Expenses

Health insurance reimbursement covers hospitalization costs, doctor consultations, diagnostic tests, medicines, and other eligible expenses. If you have additional coverage, you can claim amounts beyond what is covered under cashless treatment.

5. Useful When a Cashless Facility is Unavailable

Sometimes, cashless claims are not possible due to network hospital issues or insurance approval delays. Reimbursement ensures that even if you pay upfront, you can recover your expenses later.

How to Submit a Health Insurance Reimbursement Claim?

Filing a health insurance reimbursement claim is simple if you follow the right steps. Here’s what you need to do to claim the reimbursement smoothly:

Step 1: Inform Your Insurance Provider

Notify your insurance company or Third Party Administrator (TPA) about the hospitalisation. The deadline for intimation depends on whether the hospitalisation is planned or an emergency:

• Planned treatment – Inform your insurer at least 48 hours before hospital admission.
   
• Emergency hospitalisation – Inform within 24 hours of admission.

Most insurers allow intimation through their website, mobile app, customer care number, or email.

Step 2: Get Treated and Pay the Bills

Focus on your treatment. Once discharged, settle the full hospital bill. Since this is a reimbursement insurance claim, you must pay all expenses first.

Step 3: Collect All Medical Documents

Before leaving the hospital, ensure you have:

✔ Original hospital final bill
✔ Payment receipts for all expenses
✔ Detailed hospital bill breakup
✔ Discharge summary
✔ Investigation reports (X-ray, blood tests, scans, etc.)
✔ Doctor consultation papers and prescriptions
✔ Medicine bills with prescriptions
✔ Implant stickers/invoices (if applicable)
✔ Medico-legal certificate (MLC) or FIR (if hospitalisation is due to an accident)

If the insured person passes away during hospitalisation, additional documents like the death summary and legal heir certificate may be required.

Step 4: Fill Out the Claim Form

Download the reimbursement claim form from your insurer’s website. Fill in all sections carefully. Some forms have two parts:

• Part A – To be filled and signed by you (the claimant).
   
• Part B – To be completed by the hospital and stamped with their seal.

Attach a copy of your insurance card or policy document.

Step 5: Submit Your Claim

Send all required documents to your insurance provider. Most insurers offer:

• Online submission – Scan and upload documents through the insurer’s website or mobile app.
   
• Offline submission – Courier the hard copies to the insurer’s office within 15 to 30 days from discharge.

Also, include:

✔ Copy of government ID proof (Aadhaar, PAN, or passport)
✔ Bank details (cancelled cheque, passbook copy, or bank statement) for direct transfer of the claim amount
✔ Cover letter with your contact details

Step 6: Claim Verification and Approval

Once your insurer receives the documents, they will verify the details. If anything is missing, they will request additional information.

Processing time varies, but insurers usually approve or reject claims within 30 days of receiving complete documents.

Read More: How to Claim Health Insurance in India: A Complete Guide

Step 7: Claim Settlement

If approved, the insurance company transfers the reimbursed amount directly to your bank account. If deductions apply, they will provide a detailed explanation.

Can Medical Insurance Claims Be Denied?

Yes, a health insurance reimbursement claim can be denied if certain conditions are not met. Understanding the common reasons for rejection can help you avoid issues and ensure a smooth claim process.

1. Missing or Incorrect Documents

If any required document is missing, incomplete, or contains incorrect details, your claim may be delayed or rejected. Always double-check your paperwork before submission.

2. Claiming for Excluded Treatments

Every health insurance policy has specific exclusions. If your treatment falls under an exclusion (such as cosmetic procedures or pre-existing conditions not covered under the policy), the insurer may deny your claim.

3. Delay in Submitting the Claim

Insurance companies have a time limit for submitting reimbursement insurance claims, typically 15-30 days from discharge. Missing this deadline can lead to claim rejection.

4. Hospital Not Meeting Insurer’s Criteria

Some insurance providers require treatment at a registered hospital with a minimum number of beds and proper licensing. If your hospital does not meet these conditions, your claim may be denied.

5. Policy Lapse or Insufficient Coverage

If your policy was inactive due to non-payment or if the treatment cost exceeds your sum insured, the insurer may reject or partially approve the claim.

6. Incorrect Information Provided

Falsified details or discrepancies in medical records can lead to rejection. Always provide accurate and truthful information when filing a claim.

What to Do If Your Reimbursement Claim Is Rejected?

A rejected health insurance reimbursement claim can be frustrating, but it does not always mean the end of the road. You can take corrective steps to get your claim reconsidered.

1. Understand the Reason for Rejection

The insurer will provide a reason for rejecting your claim. Check the claim rejection letter or email to identify what went wrong. It could be missing documents, policy exclusions, or incorrect details.

2. Cross-Check Your Policy Terms

Go through your policy documents to confirm whether the treatment is covered. If your insurer denied the claim due to a misunderstanding, you can use your policy details to contest it.

3. Rectify and Resubmit Missing Information

If the claim was rejected due to missing or incorrect documents, gather the necessary papers and resubmit them within the allowed timeframe. Make sure all details are accurate.

4. File a Formal Appeal

If you believe your claim was unfairly denied, you can file an appeal with your insurance provider. Submit a written request along with supporting documents explaining why your claim should be reconsidered.

5. Contact the Insurance Ombudsman

If your appeal does not resolve the issue, you can approach the Insurance Ombudsman. This is a free service that helps policyholders settle disputes with insurers.

For more information, feel free to reach out to the team of Oneassure!

Key Takeaways