Steps for Filing a Reimbursement Health Insurance Claim

Types of Health Insurance Claims:

When you have a health insurance policy and are advised of hospitalization covered under your policy, you would be able to make a claim. The kind of claim that you can make depends on the kind of hospital you seek treatment in. Fundamentally, two types of claims are admissible in a health insurance plan, these are:

1. Cashless Claims
2. Reimbursement Claims

Note: A cashless claim is when the hospital would process it on your behalf. So your involvement is minimal. However, for a reimbursement claim, you need to process the entire claim yourself.

Health Insurance Reimbursement Claim:

When making a medical reimbursement claim, the medical bills are cleared by the customer and claimed later by the health insurance company. An advantage of a reimbursement claim is that the treatment can be taken in a hospital of the policyholder's choice.

Most people consider reimbursement a quicker way in terms of the time taken at the time of discharge, as when making a cashless claim, the process of discharge is often lengthy. Till the time all formalities are completed, a patient is not free to leave the hospital. 

However, on the flip side, making a cashless claim might be considered more straightforward. Also, in a network hospital, you need not arrange any finances before the treatment, but when going for reimbursement of medical expenses, you would have to pay the bills yourself and thus raise the required funds.

Planned Hospitalisation and Emergency Hospitalisation:

Another critical factor when making a reimbursement claim is the mode of hospitalization, which may be planned or in an emergency. For example, if someone has to undergo hip replacement surgery, it would be a planned surgery. On the other hand, due to a heart attack, angiography may be required urgently. This surgery would be an emergency. 

In both kinds of hospitalization, the insurance company must be informed in time. In planned hospitalization, the notification should be done at least 3 to 4 days before the hospitalization. If it is an emergency hospitalization, the medical reimbursement request should be registered within 24 hours of hospitalization.

Steps for Filing a Health Insurance Reimbursement Claim:

For making a medical reimbursement claim, the insured member has to go through standard hospitalization and then follow a few simple steps to make a claim. Most companies follow the same procedure; however, it is recommended that you speak to a company representative in case of a concern or query.

1- Notification: 

As explained earlier, the most critical step while seeking reimbursement of medical expenses is to inform the health insurance company on time. The policyholder or someone on their behalf must register the claim as soon as possible. Depending on the company the claim system, the notification of claim can be done in the following ways:

• Calling the company customer care
• Writing an email to the company
• Registering the claim online through the official website or mobile portal/ app

2 - Treatment:

As per the doctor's prescription, the policyholder must be admitted to the hospital and receive the necessary treatment. Once the treatment is finished, the cost of treatment is to be borne by the insured member/ his family/ someone on his behalf.

3 - Discharge:

Once the insured is ready for discharge, it should be ensured that he/they or someone dependent carries certified true copies of all the bills and receipts of all investigative tests, reports, discharge summary, etc. These certificates should be stamped and signed by the hospital authorities.

4 - Claim:

Once the insured member is home, the reimbursement claim can be filed. Most companies give a period of 7 to 15 days from discharge to complete the paperwork and submit documents. If the insured member is still recovering, any responsible friend/family member can help with the formalities. 

5 - Paperwork:

All the medical reports, doctors' certificates, and bills must be submitted to the insurance company within the period. Due to the ongoing COVID-19 situation, most companies ask policyholders to submit the medical documents online or via email. Once the details and documents are verified, the claim will be reimbursed. 

6 - Reimbursement Claim Status:

Most companies settle reimbursement claims with a period of 7 to 15 working days. 

Multiple Claims:

In case a policyholder has invested in 2 health insurance policies or is making use of a top-up or a super top-up policy, he has the option of making multiple claims. The combination can be:

• Cashless + Cashless
• Cashless + Reimbursement
• Reimbursement + Reimbursement

In such a case, the reimbursement claim would remain the same. The insured/ someone on his behalf would have to follow the same procedure for making multiple claims with the same/ different health insurance company.

Things to Remember When Filing a Reimbursement Claim:

The sole aim of having a health insurance policy is an easy and hassle-free claim. The policyholder should follow the claim procedure cautiously so that there are no difficulties. For a smooth claim, the following points should be remembered:

1. There should not be a delay in informing the company about the hospitalization.
2. A responsible friend/family member should be appointed to help the insured member with the formalities.
3. Regular updates from the TPA or the health insurance company should be taken. 
4. Authentic Copies of all Reports, Bills & Receipts, Investigative Reports, Doctors' Prescriptions, Discharge Summary, etc., should be taken from the hospital.

The Bottom Line:

There is most people aren't aware of how a health insurance plan works. Lack of knowledge about the reimbursement claim settlement procedure is also why people feel apprehensive about investing in a health plan. They are worried that their claim may not be settled at the crucial hospitalization time or delayed settlement.