Reimbursement Claims Process in Health Insurance

Having a health insurance policy can be useful when a medical emergency strikes. You can raise a claim with your health insurance provider in such a situation. Once the claim is processed and settled, the insurance company can help in regard to the financial payment for the treatment of the medical emergency.

* The process to raise a claim can differ between insurance companies.

There are two types of claims as well - cashless claims and reimbursement claims. In a cashless claim, the insurer takes care of the payment directly with the network hospital. In a reimbursement claim, the policyholder can choose a hospital of their preference and pay for the treatment expenses. They will be reimbursed by the insurer later.

*Claims are subject to the terms and conditions set forth under the health insurance policy.

Let us take a detailed look at the reimbursement claim process of Bajaj General Insurance Limited.

How Does Reimbursement Health Insurance Work?

Let us examine how reimbursement health insurance functions and how it varies from its counterpart:

1. You are protected under the terms and conditions of the reimbursement health insurance plan after you purchase it.
2. You can receive medical care at any hospital of your choosing in the event of an emergency.
3. For the time being, you would have to pay for the procedure. All of your papers, bills, and receipts must be kept securely with you.
4. If your health insurance plan covers the medical costs, you must file a claim with the insurance company as soon as you can, and do so within the allotted period.
5. You must complete the appropriate form and provide the insurance company with the required documents to file a claim.
6. The insurer will verify the claim documents when they are filed. They could get in touch with you if they need any more help.
7. In compliance with the terms and conditions of the policy, you will get coverage for medical costs if the claim is accepted.

How to Raise a Reimbursement Health Insurance Claim

Keeping your care and comfort in mind, we, at Bajaj General Insurance Limited, have created a simple, no-frills health insurance claim procedure. Here is the process, categorised into different steps for a clearer understanding:

1.      Intimate the Insurance Company

We understand that in times of medical crisis, you may find it difficult to reach out to the insurance company right away. However, we request you reach out at the earliest you can. In case of planned hospitalisation, you can also inform us prior to the admission, so that there is a lesser strain on you during the hospitalisation process.

2.      Pay Bills and Collect Documents

As you have opted for a reimbursement claim, you must pay the bills from your pocket for now. Ensure to keep each bill and invoice safe with you. Along with the bills, you also need to collect other hospitalisation-related documents in the original. A list of documents needed to claim health insurance is available in a later section of the article.

3.      Submit the Claim Form and Documents

Now, after the payment process has been completed from your end, you need to share the relevant documents with the insurance company. You also need to fill out the claim form with the right information. In case you need help in knowing How to fill Final Claim Form, you can view this resource to get the assistance you need.

4.      Let the Insurance Company Verify and Enquire

Based on the information submitted by you, the insurance company will verify the claim. In case more information is needed or there is a deficiency of certain documents, they will reach out to you. Once all requirements have been satisfied, the insurance company will settle the claim within a specified number of days.

At Bajaj General Insurance Limited, you can bank on us to initiate the health claim settlement process and release the payment within 7-10 working days. Claims are subject to terms and conditions set forth under health insurance policy.

Note: You can raise a health insurance claim digitally as well. The reimbursement claim form can be availed by visiting the website of the insurance company or by running a search.

Also Read: Reimbursement Health Insurance: What You Need To Know

Documents Needed for Reimbursement Health Insurance Claim

Along with the claim form, the documents required for Mediclaim reimbursement process are as follows:

●       Discharge summary of the patient (original)

●       Hospital bill, with a detailed break-up of the costs (original)

●       Paid receipts (original)

●       Lab and test reports

●       Copies of invoices/ stickers/ barcodes in case of implants

●       First consultation letter from a doctor

●       KYC form

●       NEFT form, filled and signed by the policyholder/ proposer

In case the insured person has passed away during hospitalisation, additional documents, such as the original death summary document and legal heir certificate might be required.

*Claims are subject to terms and conditions set forth under health insurance policy.

Can a Health Insurance Claim be Denied?

Yes, the insurance company can reject your claim due to several reasons. Broadly, the claim may be rejected if it does not fall into the insurance policy’s purview. Some specific reasons which may lead to health insurance claim rejection include:

●       Treatment for an illness/ medical event not covered by the health insurance plan.

●       Suppression or misrepresentation of a relevant medical fact by the policyholder.

●       Treatment and the subsequent claim found to be unnecessary and unsupported/ fraudulent.

●       Claim made during the waiting period for a specified or pre-existing disease as listed in the policy.

A claim can be denied for multiple other reasons. To get a complete list of the exclusions, you should read through the entire contents of your health insurance policy document. Knowing how to raise a claim and the documents required for it can be helpful in times of emergency. If you have health insurance for family coverage, make sure your loved ones are also aware of the claim process. This can help them be stress-free in times of medical emergency. For additional assistance, you can also reach out to us at 1800-209-5858 or email us at: careforyou@bajajgeneral.com.

*Claims are subject to terms and conditions set forth under health insurance policy.

Also Read: Types of Health Insurance

What Happens if the Reimbursement Claim Gets Rejected?

Let us say you filed a claim with Bajaj General Insurance, but it was denied for whatever reason. Typically, we will give you three reminders, each ten days apart, if any papers are missing. This will provide you with enough time to organise the required documents. Nevertheless, the claim will be terminated after 30 days if the documents are not organised.

Follow the steps below if you have found out that your claim has been denied:

1. Know the reasons behind your claim rejection.
2. Correct the error and submit the claim again.
3. If you think there has been a misunderstanding, draft an appeal letter supporting your position with policy provisions.
4. Inform the IRDAI Grievance Officer about the issue.
5. Insurance Ombudsmen will confirm the facts and render an impartial decision.

Types of Health Insurance Claim

There are mainly two types of claims: reimbursement and cashless claims. Let us take a closer look at them:

1.      Reimbursement Claim

In the reimbursement claim process, you have to pay the upfront cost of the treatment and then submit a claim form with all other necessary documents to the insurance company. The insurance company then verifies the claim and, after its approval, pays the expenses.

It gives you the flexibility to choose any hospital, make personalised healthcare decisions, and have less dependency on network hospitals.

2.      Cashless Claim

Such claims are filed directly by the hospital and the insurance company. You do not have to pay for the medical care since the insurer pays the hospital's charges directly. However, this is only applicable when the hospital is on the insurance company.

Cashless vs Reimbursement Claim

Features and Benefits of Reimbursement Health Insurance

1.      Flexibility

In the case of cashless health insurance, you can only choose the network hospitals of your insurer. However, in the case of reimbursement for health insurance, you can freely choose any hospital for treatment.

2.      After Treatment Claims

One of the advantages of the reimbursement claim process is that you can apply for your claim after your treatment process and after paying your bills. This makes sure that there will be no administrative hassles for you during your treatment. Rather, you can relax and recover.

3.      Personalised Healthcare Choices

The other benefit of reimbursement health insurance is that you can make decisions about your medical treatments according to your own choices and requirements.

Things You Should Consider Before Opting for Health Insurance Reimbursement Claims

1.      Maintain All Medical Records

Do not forget to save all medical treatment-related receipts and documents for future use.

2.      Coverage

To ensure the plan covers the costs you have chosen, you must carefully review your policy. It might be a waste of time and effort to file a claim for a medical condition that might be excluded.

3.      Claim Time Limits

Every insurance policy has a deadline for filing a claim. Therefore, pay attention to claim deadlines to make sure you submit everything on time.

4.      Sub Limits

Certain health insurance policies contain a room rent sub-limit, which means that medical costs covered by ‘room rent’ will only be paid up to a certain sum or a portion of the total.

Inclusions in a Mediclaim Reimbursement Claim

To prevent any surprises during claim settlement, it is essential to review your insurance contract for precise inclusions and exclusions. A standard reimbursement health insurance coverage pays for several costs, including:

1. hospitalisation costs
2. pre- and post-hospitalisation expenses
3. diagnostic tests
4. Ambulance charges
5. Surgeries
6. Cancer treatments
7. doctors’ fees
8. Joint reconstruction or replacement
9. Daycare procedures
10. AYUSH treatments
11. Domiciliary treatments
12. Special treatment

Conclusion

The reimbursement claim process in health insurance may require more administrative effort, but it provides more flexibility and control over your healthcare decisions. A thorough review of the policy, proper documentation and timely claim submission are key factors to a smooth claim experience.

Just knowing the basic process will help you to confidently deal with unexpected hospital costs.

You can also choose Bajaj General Insurance to have a hassle-free claim settlement process. Our seamless services help us maintain excellent customer relations, and we have a high claim settlement ratio.

FAQs

1.      What is a reimbursement claim in health insurance?

It’s a process to recover medical expenses from your insurer for treatments taken at non-network hospitals by submitting bills and documents.

2.      How do I file a reimbursement claim?

Notify your insurer, gather necessary documents, submit the claim form, and await approval for reimbursement.

3.      What documents do I need for a reimbursement claim?

You’ll need original bills, discharge summary, prescriptions, diagnostic reports, a completed claim form, and identity proof.

4.      How long does it take to get reimbursed?

It typically takes 15–30 days after submitting all required documents.

5.      Can I claim reimbursement for non-network hospital treatments?

Yes, provided the expenses fall under the coverage of your policy.

6.      What if I miss submitting some documents?

Your claim could be delayed or rejected. Insurers may request additional documents if needed.

7.      Why could a reimbursement claim be rejected?

Claims may be denied due to exclusions, incomplete documentation, or submission after the allowed time.

8.      How can I check my claim status?

Log in to your insurer’s online portal or contact their customer service to track your claim.

9.      Is there a deadline for claim submission?

Most insurers require claims to be submitted within 30–90 days of discharge.

10.  What should I do if my claim is rejected?

Review the reason, provide additional documents if needed, or appeal with the insurer for reconsideration.

11.  Are there any waiting periods for specific treatments or conditions in my policy?

Most policies do have a waiting period for some treatments or pre-existing conditions. Check your policy document for more details.

12.  What healthcare expenses in a health insurance policy can be reimbursed?

The reimbursement claim process usually covers expenses such as hospitalisation costs, diagnostic tests, surgeries, and post-hospitalisation treatments.

13.  How does reimbursement for medical work in health insurance?

You have to pay out of pocket for your treatment in a non-network hospital. Then, you will need to submit original bills and reports to your insurance company to recover these costs.

14.  What to do if I cannot visit a network hospital?

Go to the nearest hospital, get treatment, and pay the bills. Then submit all original medical documents and receipts to your insurer to claim reimbursement.

15.  What does health insurance cover?

Standard health policy covers expenses related to inpatient hospitalisation, pre- and post-hospitalisation, day-care procedures, ambulance and ICU charges. Please see your individual policy document for specific inclusions and exclusions.

* Standard T&C apply

Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.

*Standard T&C apply. Disclaimer: The content on this page is generic and shared only for informational and explanatory purposes. It is based on several secondary sources on the internet and is subject to changes. Please consult an expert before making any related decisions. Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.