A Guide to Health Insurance Reimbursement

Did you forget to apply for a cashless claim? Or was your cashless claim got rejected? Health problems are painful and their treatment is expensive. But you don’t need to get worried as you can reimburse the money you have paid out of your pocket for your medical treatment through insurance reimbursement.

In health insurance, there are two types of claims – cashless and reimbursement. A cashless claim is settled directly by the insurance company. On the other hand, in reimbursement, the policyholder pays the medical bills, then seeks the company to reimburse him.

What is reimbursement in Health Insurance?

When an insurance policyholder pays the medical expenses out of his pocket, then the insurance company repays the policyholder as a reimbursement claim. Point to be noted, the policyholder is required to seek approval from the insurance company for medical reimbursement.

When Can a Reimbursement Claim Arise?

1. When the insurance company does not provide a cashless facility.
2. When the insured fails to intimate the insurance company about the hospitalization.
3. When there was an emergency, the insured was admitted to a non-network hospital.
4. When the cashless claim was rejected by the insurance company.

What Is Covered in the Reimbursement Claim?

The following medical expenses can be reimbursed:

1. Hospitalization expenses
2. Pre and post-hospitalization expenses
3. Ambulance charges
4. Day-care treatment
5. Room rent
6. ICU charges
7. Doctor’s consultation fee
8. Surgery
9. Medicines and drugs etc
10. Other costs are included in the terms and conditions of the policy document.

Benefits of Reimbursement in Health Insurance

1. Stress-free at the time of emergencies: During emergencies, you don’t need to take stress about locating a network hospital. You can immediately get admitted to any nearby hospital
2. Can take treatment from any hospital: You can get admitted to a hospital of your own choice. You don’t need to find a network hospital. However, hospitals need to be regulated as per the guidelines of the insurance company. All insurance companies prefer a registered hospital with a minimum of 25 beds and having all basic medical facilities. A nursing home can not be called a hospital
3. Can apply for a claim after taking the treatment: You can apply for a reimbursement claim once the treatment is availed and bills are settled. Even in case of a cashless claim is rejected, you can apply for reimbursement. But, please note that the claim will be reimbursed as per the guidelines of the insurance company. Generally, 80% of expenses are reimbursed.

How Do I Claim Health Insurance Reimbursement?

1. Intimate your insurer

Any family member or the insured must notify the insurer/TPA about the hospitalization within a reasonable time. He should send the following details of the insured to the company:

• Policy number
• Name of the hospital
• Name of the doctor

2. Verify and settle hospital bills

Verify that the details in the bills do not have any discrepancies. After verification, settle all the hospital expenses.

3. Submit the reimbursement form

You must fill out the reimbursement form and submit it to your insurance company. Along with the reimbursement form, submit the following documents:

• Original hospital bills
• Cash memos
• Prescriptions
• Medical reports and tests
• Hospital admission slip
• Discharge summary
• FIR copy in case of an accident claim

There can be other documents required by your insurer.

4. Wait for payment processing

The insurance company will investigate your case and then decide whether to approve the claim or deny it. If approved, a cheque will be disbursed or the reimbursement amount will be directly transferred to the insured’s account.

If you are not satisfied with the claim settlement, you can reapply.

Things to Remember

• You must inform your insurance company within the stipulated time as a delay in informing may lead to a claim rejection.
• You must fill out the reimbursement form correctly.
• The information provided to the insurance company must be correct.
• Before filing a claim, you must read the insurance policy document. If you are hospitalized due to a reason which is mentioned in the exclusion list of the policy document, the claim will be rejected.
• Remember to submit all the required original bills to the insurance company. If you fail to furnish all the required bills within the specified time, then the claim may get rejected immediately.

If you are not satisfied with your claim settlement, you can reapply for the claim. If you need assistance with your claim settlement, you can contact Insurance Samadhan.

Insurance Samadhan has resolved 14500+ customer complaints related to insurance. We’ll be happy to help you.

Click on the below links to read some cases resolved by Insurance Samadhan:

Health Claim Rejection amid Covid-19

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