Reimbursement claim

Last time we talked about cashless claims. Let us know about the reimbursement claim this time. This is called reimbursement. Thus, for a reimbursement claim you have to pay for the treatment out of your own pocket and then the health insurance company gives you reimbursement based on the proof of expenses you have submitted.
When it comes to hospitalization of any insured, it is necessary to first check the network of the insurance company and the availability of a doctor treating the related illness. At the same time, the room rent limit set by the insurance company should be taken into consideration. Since the cost of hospital treatment depends entirely on the range of rooms selected, the choice of range needs to be made judiciously. Cashless claims are possible if the hospital is within the insurance company’s network, otherwise the reimbursement option remains.
Reimbursement Claim Procedure:

Claim report

The third party administrator / insurance company must be notified within 3 hours of admission when seeking treatment in a hospital outside the network. In case of delay in reporting, the cause of delay has to be disclosed to the insurance company at the time of claim settlement.

Preservation of documents

All hospitalization documents need to be preserved for easy reimbursement. Tests performed to diagnose the disease, the cost of treatment taken by another doctor before being admitted to the hospital, test reports, chemist’s bill are all proofs required. In addition to all these details, even after admission to the hospital, it is necessary to take the original of all the documents along with the discharge summary given by the hospital at the time of last leave.

Signature-coins on documents

When taking leave from the hospital, details should be filled in Part B of the claim form and signed by the hospital. All the required documents along with the form are to be submitted for reimbursement claim.

To submit documents

All medical bills, reports, discharge summaries, hospital or doctor’s prescriptions, should be kept in a separate file of all documents, which must be sent to a third party administrator with a claim form to process the claim. Keep a copy of the documents in your file for your records before sending it.

Claim settlement and approval

After the documents are submitted to the third party administrator / insurance company, it is verified and compared with the policy terms and the sum insured. The claim is approved after completion of the verification and the sanctioned amount is credited to the insured’s account. Generally, the claim is processed and approved within thirty days after all the documents have been submitted. If any document is lacking, it is requested from the insured. If the insurance company delays the claim settlement, as per the guidelines of the Insurance Regulatory and Development Authority of India (IRDI), interest has to be paid in addition to the claim settlement amount.

Claim under more than one policy

If the policyholder has taken more than one policy, after processing the claim submitted to the first company / third party administrator, the company will issue a letter of settlement and a signed copy of every document submitted to him will be given to another company. If there are more than two policies, the same procedure will apply to each policy.


The claim will be settled in accordance with the terms and conditions of the policy. Therefore, if there is any deficiency in the bill, report or other documents or the category of the room is different, then the entire claim will not be passed. Therefore, it is important to pay more attention to every detail while making a reimbursement claim as compared to a cashless claim.

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