Ultimate Guide to Filing a Health Insurance Reimbursement Claim

Reimbursement For a Health Insurance Claim

Filing a Reimbursement Health Insurance Claim

What is Health Insurance Reimbursement

Health Insurance policy allows you to claim money for costs that you incur to obtain healthcare benefits from a hospital / doctor based on your policy terms. These benefits can be claimed as a Cashless Claim or a Reimbursement Claim. A reimbursement claim is that where in you have already made expenses for healthcare services and now would like to get indemnified  by the insurance company from whom you have obtained your policy. 
Health insurance policy pays on the basis of the coverage mentioned in your policy document. This process is well defined and takes up to 30 days for the money to be paid back to you.

What can I claim Reimbursement for under Health Insurance

The claims filed under health insurance can be for the main hospitalisation expenses or can be for pre-hospitalisation and post-hospitalisation expenses. In either of the cases, the process is the same. 

How do I get Reimbursement for my Health Insurance

You will need to fill a claim form and provide all documents in original for getting paid under your health policy. 
Please read the claim form carefully before you start filling up. Please mention your employee ID and contact details on top of the claim form. You can write this at the right top portion of the claim form. Please note that the following fields are mandatory in a claim form as you begin filling it up - 
  1. Policy Number
  2. Insurance Card Identity number
  3. Name of the insured with addresses and contact details
  4. Name of the corporate & employee code (In case of group health insurance policy )
  5. Name of the patient, date of birth and relationship with the employee
  6. Tick on the type of claim, write, and date of admission and discharge, name, address and contact details of the hospital
  7. Provide the details of illness / injury
  8. Provide the details of amount is being claimed with break of bill numbers
  9. All documents in original mentioned in the claim form
  10. Signature of the claimant along with place and date is mandatory
  11. Once the claim form is filled you need to submit the claim form along with all mandatory documents.
Following original documents are mandatory to process a claim under reimbursements -  
  1. Copy of Hospital Registration Certificate with Registration Number and confirmation on number of beds 
    1. Note that the hospital should have a minimum of 15 beds in urban areas and 10 beds in rural areas to qualify for being a hospital. Alternatively it should be registered with the local relevant government authorities
  2. Claim Form duly signed
  3. Copy of the claim intimation, if any
  4. Hospital Main Bill Proper Breakup
  5. Hospital Bill Payment Numbered receipt for which the employee made the payment to the hospital
  6. Proper Original Hospital Discharge Summary. The discharge summary should include the following
    1. Patient name,
    2. Date of admission ( and time of admission ) - Date of discharge ( and time of discharge )
    3. Age or date of Birth of the patient
    4. Final Diagnosis
    5. Case Summary / History 
    6. Course in Hospital - Line of Treatment
    7. Advice at Discharge with
    8. Sign & stamp of treating Doctor and on hospital letterhead
  7. Others Medical Document (IPD papers, Treatment Chart etc) - ( may be required - case to case )
  8. Operation Theatre Notes ( may be required - case to case )
  9. Doctor’s Prescriptions
  10. Doctor's request for investigation
  11. Copy of photo ID card of patient and employee ( in case of group policies ) 
  12. Pharmacy bills
  13. MLC report & Police FIR - required in case of accidental claims or those involving any kind of legal requirement
  14. Alcohol declaration in case of accidental ( RTA or otherwise ) claims
  15. Detailed circumstance of the trauma with date, place and time, Certified by the treating Doctor in case any type of Accident, It’s mandatory for reimbursement claim
  16. Original death summary from hospital where applicable in case of Death case
  17. ECG /CT/MR/USG/HPE investigation reports 
  18. Original cancelled cheque with printed name for the transfer of payment to the bank account or if you providing cancel cheque without printed name please submit the hard copy of passbook copy with bank attested
  19. Bank E-statement (In case your name as an policyholder / employee is not printed on the cancelled Cheque)
  20. Patient’s Government issued valid ID proof with date of birth and photograph (Pan Card, Driving License, Passport, Aadhar Card)  

Where to submit documents for a health insurance reimbursement claim

You can send the documents to the address mentioned in the policy document. There are 2 ways this may be applicable for you 
  1. Group Policy 
    1. Sending it to the Broker 
    2. Sending it to the TPA in case your policy of serviced by the TPA
    3. Sending it to the insurer directly particularly where the policy is serviced by the insurer through an in-house claim settlement team
  2. Individual / Family Policy
    1. Sending it to the TPA in case the policy is serviced by them
    2. Sending it directly to the insurer for servicing by in-house claim settlement team

How long does it take to process an insurance claim

The IRDAI regulations are clear that an insurer has to process and finalise the settlement of the claim within 30 days of the document submission. In case there are further documents needed or clarifications requested by the claim processing team, then this timeline of 30 days starts from the date of the last document submitted. In a fraction of cases where there is a need to do investigation into a claim, the insurer can exceed this timelines while keeping it reasonable. 
In case of delay in claim settlement by the insurer there is also a provision of financial penalty being levied on them
Under normal circumstances, as the industry has evolved over time, the insurer / TPA takes approximately 10-15 working days to process the claim. Once the claim is processes, the payment will be transferred directly to your bank account as per the bank details provided by you at the time of submission of the claim. This payment will come directly from the insurer even if the policy is processed by a TPA. Along with this, you should also get a claim settlement note or explanation of benefits. This document will give you details of the items on which the claim has been partially paid. Typical deductions in this are account of policy terms and within that the non-payable items. 

Delays in Health Insurance Claim Settlement

There are times when the TPA may request you to provide additional information when there is some shortfall in the documents submitted by you. Such could be either to ascertain / confirm that the treatment is aligned to the coverage under your corporate health insurance cover, or they may request for some cost breakup details etc. These, unforeseen and relatively few interventions, may delay the processing of your claim which will further delay the payment. Hence, you need to immediately furnish the documents requested by the TPA to ensure speedy processing of your claim.

Claim intimation ( Do note that this is an important clause ) - You should intimate the Insurer / TPA within 24 hours of hospitalisation in case of unplanned and before 48 hours of hospitalisation in case of planned treatments. This will be applicable for both cashless as well as reimbursement cases.

Please get in touch with us at any stage of your hospitalisation requirements in case you need support. Our team is especially trained to make sure that the navigation of your benefits results in full disbursal of the claim if you need it. We ensure that your case is presented accurately with the insurer / TPA and no delays or rejections occur unjustly. As a broker, we represent your interests above all. Our commitment and actions are aligned to ensuring that the process is smooth for you. 

Happy Health To All
Team PlanCover