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Health insurance is made to support you during medical emergencies, but many people always get confused when it comes to making a claim, especially a reimbursement claim.
In simple words, a reimbursement claim means that you first pay the hospital bill from your own pocket and then ask the insurance company to give the money back. This type of claim is useful when you get treatment at a hospital that is not on your insurance company’s network list (also known as a non-network hospital).
So if you want to know more about Reimbursement Claim in Health Insurance, read this blog. In this guide, we will discuss the reimbursement claim, how it works, documents, and much more to give you a better understanding.
What is a Reimbursement Claim in Health Insurance and How Does it Work?
A reimbursement claim is when a person asks their health insurance company to pay back the money they spent on medical treatment. Let’s understand it with an example:
Mr. Sharma has a health insurance policy. One day, he needed surgery. But instead of going to a hospital that is partnered with this insurance company (a network hospital), he went to a different hospital because he trusted the doctor there. This hospital was not covered by his insurance company. So, Mr. Sharma paid the full hospital bill from his own pocket. After the surgery, he got all the bills, prescriptions, reports, and other related and required documents.
Then, he filled out a reimbursement form with his personal details, policy number, and a list of expenses. He sent this form to the insurance company along with all the documents and bills.
The insurance company checked everything, his policy, bills, and the doctor’s note to make sure it was all correct. Once everything was approved, they sent a refund to Mr. Sharma for the costs that were covered under his policy. This is how a reimbursement claim works. You need to pay first, and then the insurance company pays you back later.
Benefits of Choosing Reimbursement in Insurance
Reimbursement claims in health insurance give many advantages. Some of them are here:
- It Gives Freedom to Choose Any Hospital: You can get treatment at any hospital, even if it is not in your insurance company’s network. This is very helpful during emergencies when you need to go to the nearest hospital quickly.
- It Covers Many Medical Costs: Most health insurance plans pay for expenses before and after you are admitted to the hospital. You can get your money back for doctor visits, medicines, tests, and other treatment-related costs.
- It gives enough Time to make a Claim: You usually get 60 to 180 days after leaving the hospital to submit your reimbursement claim. This gives you time to collect all the bills and documents you need.
Documents Needed for a Reimbursement Claim
To apply for a reimbursement claim, you need to submit these documents:
- A claim form (properly filled out and signed)
- Medical certificate signed by the doctor
- Discharge summary from the hospital (original copy)
- All hospital bills (original copies)
- Prescriptions and pharmacy bills (original copies)
- Test reports like blood tests, X-rays, etc.
- In case of an accident, you also need to submit an FIR or a Medico-Legal Certificate (MLC).
How to Apply For a Health Insurance Reimbursement Claim?
It is very simple to apply for a health insurance reimbursement claim. Just follow these simple steps:
1Inform your insurance company
As soon as you are admitted to the hospital (or before, if it is a planned treatment), you need to inform your insurance company. Try to do this within 24 to 48 hours. This helps them guide you better in your claim process.
2Collect all Required Documents
After you get discharged from the hospital, you need to gather all the important papers, such as
- Hospital bills and payment receipts
- Doctor’s prescriptions
- Discharge summary
- Consultation reports
- Lab test or diagnostic reports
- A copy of your health insurance policy.
3Fill out the Claim form
Now, take the reimbursement claim form and carefully fill it out. You need to make sure that all the details, like patient name, hospital name, and treatment details, are correct.
4Submit everything to the insurance company
Submit the filled form and all the documents either online or by visiting the company’s branch office. Check everything to avoid any mistakes and delays.
5Claim review and payment
Once the insurance company gets your documents, it will check and verify them. If all is correct, they will approve and pay the claim. This may take a few days, depending on the case.
Things to Know Before Applying for a Health Insurance Reimbursement Claim
Before you apply for a reimbursement claim in health insurance, there are a few important things you should keep in mind:
- Understand what is covered: Read your health insurance policy carefully. Make sure the treatment or medical expense you are claiming is covered under your plan. If it is not covered, your claim may get rejected, and you may waste time and effort.
- Keep all the medical records safe: You also need to save all bills, prescriptions, reports, and hospital documents safely. These are important for your claim and may be required for further checking.
- Know the time limit to submit your claim: Every insurance company gives you a time limit to submit your claim, usually within 60 to 180 days after discharge. Make sure you send all the documents within the given time.
- Be aware of sub-limits: Some policies have limits on certain expenses. For example, your plan may only cover the amount of room rent. If your hospital charges a higher amount, then you will have to pay that amount by yourself.
- Know about cashless options: Many health insurance plans also give a cashless treatment option. This means the insurance company pays the hospital directly, and you do not have to pay by yourself. This can help in case of an emergency or big hospital bills.
Difference Between Cashless and Reimbursement Health Insurance Claims
| Difference | Cashless Claim | Reimbursement Claim |
|---|---|---|
| Definition | The insurer pays the hospital directly. | You pay the hospital first, then claim the money back from the insurer. |
| Payment Process | No need to pay hospital bills (except non-covered expenses). | You pay all hospital expenses first, then file for reimbursement. |
| Hospital Type | Only available at network hospitals. | Available at any hospital (network or non-network). |
| Documents Required at Discharge | Minimal paperwork at discharge. | Requires all original documents, bills, and reports. |
| Approval Needed | Pre-authorization from the insurer is required before treatment. | No pre-authorization is needed. |
| Time to Get Benefits | Immediately, during hospitalization. | After discharge, usually within 7–30 working days. |
| Best For | Emergency treatments at network hospitals. | Treatment at non-network hospitals or when cashless is not available. |
| Upfront Payment | Usually not required. | Required. You pay first, claim later. |
Conclusion
In conclusion, reimbursement health insurance gives you more freedom to choose any hospital or doctor, even if they are not part of your insurer’s network. Although it may take a little more time and effort to collect all the documents, it helps you stay in control of your treatment. To make the process smooth, always read the policy document carefully, keep all the documents safe, and submit the claim on time.
FAQs
A reimbursement claim means you need to pay first to the hospital, and then ask your insurance company to give you the money back. This is useful if you take treatment in a hospital that is not linked with your insurance company.
You should apply for a reimbursement claim soon after you leave the hospital. Most insurance companies give you 60 to 180 days to send all the documents and apply for the claim.
Yes, you can go to any hospital, even if it is not in your insurance company’s network. But you will have to pay first and then claim the money later.
You will need original hospital bills, discharge summary, doctor’s prescription, test reports, your health insurance policy, and a filled claim form. In case of an accident, you also need to submit an FIR or MLC.
Once you submit all the correct documents, it may take about 7 to 30 working days for the insurance company to check everything and send you the money.
If you do not send your claim within the given time (usually 60 to 180 days), your claim may get rejected. So always try to apply on time.
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