How to File a Reimbursement Claim Under Health Insurance?

As the word suggests, in a medical reimbursement claim, the insurer reimburses the covered medical expenses after you have paid the bills. In other words, you have to first clear all the hospital bills, file a claim, and receive the reimbursement.

Unlike in the cashless claim option where you do not have to pay anything from your pocket upfront, in a reimbursement claim, you have to bear all the reimbursable medical expenses first and receive funds later.

There are a few scenarios under which a policyholder might have to opt for a mediclaim reimbursement:

The insurer does not offer a cashless settlement option. While this is rare, there are still a few insurers who do not offer cashless settlements. In such cases, a reimbursement claim is the only choice.

You are getting treated at a non-network hospital either due to an emergency or out of choice. The insurer can offer cashless claim settlement only at network hospitals. Hence, in such cases, you will have to opt for a medical reimbursement claim.

The insurance company rejects your cashless claim request for some reason. While you might not know the reason right away, the only other thing you can do is to get treated, pay the bills, and submit a medical reimbursement application letter along with the required forms and documents.

**Step 1:Inform the Insurer: Before you get hospitalised, make sure that you inform the insurer at least 48 hours in advance. This is possible only in planned treatments.

If you are faced with a medical emergency and need to get hospitalised immediately, then ensure that you inform the insurer within 24 hours of being hospitalised.

**Step 2:Focus on getting treated: Since there is no cashless option (for any of the reasons listed above), focus on getting the treatment done and arranging the funds needed for the same. Remember, you will have to clear all bills and get discharged before filing a claim.

**Step 3:Clear all bills: Make sure that you clear the hospital bill in full.

**Step 4:Get your medical file in order: To file a reimbursement claim, you will need all the documents about your treatment. The best thing to do is to make a file with all the papers right from the initial diagnostic tests to consultation, hospital bills, and the discharge letter.

**Step 5:Initiate the claims process: After you are discharged, contact the insurer to start the claims process. Fill out the medical reimbursement claim form, attach documents, and submit the file to the insurer within the stipulated time frame.

Insurers specify the period during which you need to submit a claim after being discharged. Ensure that the claim request is submitted within that period.

**Step 6:Await a response: After receiving your request, the insurer will verify all documents and calculate the amount that can be reimbursed based on the scope and extent of coverage of your policy.

You will typically hear from the insurer within 30 days with the status of your claim – accepted, rejected, or more documents needed.

**Step 7:Receive the claim amount: Once your application is approved, you will receive the claim amount.

While the list of documents might vary based on your policy and treatment, here is a common list of documents needed to initiate the Mediclaim reimbursement process:

Make sure that you are aware of the exact coverage offered by your policy. Read the inclusions and exclusions thoroughly.

When you buy the policy, ensure that you talk to the insurer to understand the complete claims process to avoid any surprises when you file a reimbursement claim.

When you submit the claim, keep a copy of the claim form and all the documents sent to the insurer. Remember, you will be submitting many original documents. Hence, you might want to keep a copy in case you need them later.

When buying or renewing a policy, always research your options and look for the best health insurance plans based on your needs. This will help iron out a lot of creases while filing a claim.

Reimbursement claim is a beneficial claim filing option when you want to get treatment outside the set of network hospitals for cashless claims of an insurer. Under reimbursement claim, you can get the medical treatment and claim the bill later with your insurer.

With Tata AIG health insurance plans, you get to choose from a wide network of 10,000+ hospitals to get cashless treatment up to the policy limit. Moreover, you get a smooth and quick reimbursement claim settlement process if the need arises.

What is the time limit for medical bill reimbursement?

The time taken by the insurer to process your claim can vary based on many factors. Usually, the claims are processed within a few weeks of being received. However, you can talk to your insurer to get a clear idea about the timeframe within which you can expect it to be processed before and after approval.

What is better: cashless or reimbursement?

Most people prefer cashless claim settlement since it is a hassle-free process and they are not required to pay from their pockets first and claim the amount later. However, in cases where cashless settlements are not possible, reimbursement claims are equally efficient ways of getting the claim amount from the insurer.

Is there a limit on the number of medical reimbursement claims I can file in a year?

Usually, there is no limit on the number of claims you can file in a year. Some insurers might put a cap on the amount of claim per illness or based on any other factor. Hence, it is prudent to talk to the insurer to understand if there are any such limits set.

What happens if my reimbursement claim is denied?

Typically, when a claim is denied, the insurer sends a letter to the policyholder explaining the reason behind the denial. If you can attach some additional documents to correct any oversight or errors, then your claim might get processed. However, if you want, you can also talk to the insurer and try to find a solution.