Reimbursement in Health Insurance Claim: All You Need to Know

Health Blog
08 Jun 2026
Bajaj General Insurance
617 Viewed

Contents

How Does Reimbursement Health Insurance Work?*
Steps on How to Make a Reimbursement Claim Under Bajaj General Insurance
Health Insurance Reimbursement Documents List
What Happens if the Reimbursement Claim Gets Rejected?
Types of Health Insurance Claim
Cashless Vs Reimbursement Claim
Features and Benefits of Reimbursement Health Insurance
Things You Should Consider Before Opting for Health Insurance Reimbursement Claims
Inclusions in a Mediclaim Reimbursement Claim
Conclusion
Frequently Asked Questions

Reimbursement in a health insurance claim is a type of claim. In this type of claim, during hospitalisation, a policyholder pays for the hospital bills and later requests the insurer to reimburse for the expenses. Unlike a cashless claim, this form of claim provides flexibility to the policyholder, so they can choose any hospital for treatment without being restricted to a network hospital.

Furthermore, according to the latest Insurance Regulatory and Development Authority of India (IRDAI) regulation, policyholders can apply for a reimbursement claim now even after the insurer stipulated deadline.

These are the reasons why policyholders choose reimbursement for health insurance claims. In this blog, you will get all the necessary information related to reimbursement claims.

How Does Reimbursement Health Insurance Work?*

To understand how reimbursement health insurance works and differs from its counterpart, let us see how it works.

1. Once you buy the reimbursement health insurance plan, you are covered under it as per its terms and conditions.

2. In the case of a medical emergency, you can seek medical treatment at any hospital of your choice.

3. The treatment expenses would have to be borne by you for the moment. You must keep all the bills, receipts and records safely with you.

4. Once you can, you must submit a claim to the insurance company for the medical expenses (if they are covered within the health insurance plan) within the stipulated time.

5. For the claim, you must fill out the relevant form and submit the necessary documents (bills and other medical records) to the insurance company.

6. Once submitted, the claim documents will be verified by the insurer. In case of any additional assistance, they may reach out to you.

7. If the claim is approved, you will receive the payment (i.e., the reimbursement) for the medical expenses, in accordance with the policy’s terms and conditions.

Apart from reimbursement and cashless claims, some general insurance plans, such as critical illness insurance, have a benefit-based claim process. Here, the insurer makes a pre-defined payout (after which the policy may cease to operate) if the insured person is diagnosed with a particular illness or has to undergo surgery. These are called defined-benefit health insurance plans.

Steps on How to Make a Reimbursement Claim Under Bajaj General Insurance

Are you wondering “Which steps to follow for a reimbursement in a health insurance claim”? Then follow these steps:

Step 1: Inform your insurer (Bajaj General Insurance) about the hospitalisation.

Step 2: Visit a non-network hospital for the required treatment and pay upfront.

Step 3: After discharge, arrange all the hospitalisation-related documents, such as the bill, doctor's prescription, discharge summary, etc., and submit them to our Health Administration Team (HAT).

Step 4: We will verify the documents, approve and initiate the reimbursement.

Step 5: You can expect the reimbursement within 10 days.

Health Insurance Reimbursement Documents List

While making a reimbursement claim, ensure that you have the following:

1. Duly filled reimbursement form

2. Original bills and receipts

3. Discharge summary

4. Doctor’s prescription

5. Diagnostic test reports

6. Policy details

What Happens if the Reimbursement Claim Gets Rejected?

Suppose you have made a claim with Bajaj General Insurance, but for some reason, it got rejected. Usually, if there are any missing documents, we will send you three reminders, each 10 days apart. This will give you ample time to arrange the necessary documents. However, in case the documents are not arranged, the claim will be closed after 30 days.

If you find that your claim has been rejected, do the following:

Step 1: Review the reasons behind the claim rejection.

Step 2: Rectify the mistake and resubmit the claim.

Step 3: Draft an appeal letter backing your case with policy terms if you see that there has been a misunderstanding.

Step 4: Contact the Grievance Officer of IRDAI, informing them of the concern.

Step 5: Insurance Ombudsmen will verify the facts and issue a fair verdict.

Types of Health Insurance Claim

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

Healthcare Reimbursement

This traditional type of claim involves paying for the medical expenses out-of-pocket and then submitting a reimbursement form to the insurance company along with all the required documents. Once the claim is verified and approved, the insurer reimburses the expenses as per the policy terms. Advantages:

1. Flexibility to choose any hospital.

2. Personalised healthcare decisions.

3. Less dependency on network hospitals.

Limitations:

1. Out-of-pocket expenses have to be borne initially.

2. Requires proper documentation and adherence to claim submission deadlines.

Cashless Claims

This type of claim is processed directly between the hospital and the insurer. The policyholder does not have to pay for the treatment, as the insurance company settles the bill directly with the hospital, provided it is a part of the insurer’s network. Advantages:

1. No upfront payment required.

2. Hassle-free treatment during emergencies.

Limitations:

1. Limited to network hospitals.

2. Pre-authorisation is required before treatment.

Cashless Vs Reimbursement Claim

Here is a difference table of cashless and reimbursement claims for better understanding:

Features	Reimbursement Claim	Cashless Claim
Meaning	Policyholder pays the hospital upfront, and later makes a claim to the insurer for reimbursement.	The insurer directly contacts the network hospital and settles the bill on behalf of the policyholder.
Claim Processing Time	Takes time since the insurer verifies all the submitted documents related to hospitalisation. It varies from one insurer to another.	Takes less time, mostly within 3 hours
Out-Of-Pocket Expenses	Higher since the policyholder pays the hospital bill upfront	Lower, since the insurer directly pays the bill, and the policyholder only needs to pay for the things that are not included in the policy term
Documentation	Thorough documentation is required, which includes original medical bills, test reports, etc.	The health insurance card needs to be submitted at the hospital's TPA desk at the time of hospitalisation.
Pre-Approval	No preapproval is necessary. However, the policyholder needs to inform the insurer before hospitalisation.	Preapproval is a must.

Choose Bajaj General Insurance’s Health Guard policy to get comprehensive coverage for your health and a seamless claim experience.

Features and Benefits of Reimbursement Health Insurance

Now that you know how reimbursement health insurance works, let’s understand how it may benefit policyholders.

You Can Choose Any Hospital You Want

Unlike cashless health insurance, where you are bound to a pre-approved list of hospitals, you can choose any hospital for treatment with reimbursement health insurance. This way, you choose a hospital where you believe you may get the right treatment.

Claim Can Be Raised Post-Treatment

One of the benefits of reimbursement health insurance is that one can apply for a claim after their medical treatment is complete and the bills are settled. This ensures that you do not have to worry about any administrative problems during your treatment. Instead, you can focus on rest and recovery.

Personalised Healthcare Choices

Your health is personal, and so should your healthcare choices. Reimbursement health insurance allows you to make your medical decisions based on your preferences and requirements. This ensures that your health insurance aligns with your unique needs, which can encourage a stronger sense of control over your well-being.

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

Also Read: Difference Between Health Insurance and Critical Illness Insurance

Things You Should Consider Before Opting for Health Insurance Reimbursement Claims

Every general insurance claim is carried out via a specific procedure. When it comes to reimbursement health insurance, these are some things you should know:

Know What is Covered

You must thoroughly review your policy to make sure that the expenses you are opting for are covered under the plan. Raising a claim for a medical issue which may be excluded may lead to a waste of time and energy.

Maintain All Medical Records

Remember to keep all receipts and documents related to the medical treatment for future reference safely.

Know Claim Time Limits

When it comes to raising a claim, every insurer has a time limit. Hence, be mindful of claim time limits to ensure that you submit everything on time.

Be Aware of the Sub-Limits

A sub-limit refers to a limitation on a particular expense related to medical treatment. For instance, some health insurance plans have a room rent sub-limit; medical expenses under ‘room rent’ shall be reimbursed only till a particular amount or a percentage of the total amount.

Know That Cashless Options Are Available

All health insurance plans are likely to have a cashless feature. So, if you are unable to pay large amounts of cash upfront for treatment, you can consider cashless health insurance as well.

Claims are subject to the terms and conditions set forth under the health insurance policy. Before you opt for reimbursement health insurance, you should get an idea of its premium. For that purpose, you can use a health insurance calculator.

Inclusions in a Mediclaim Reimbursement Claim

A typical reimbursement health insurance policy covers various expenses such as hospitalisation costs, pre- and post-hospitalisation expenses, diagnostic tests, surgeries, and doctors’ fees. However, it is crucial to check your policy document for specific inclusions and exclusions to avoid any surprises during claim settlement.

Conclusion

In conclusion, although reimbursement in health insurance claims may require more administrative effort, it offers flexibility and control over your healthcare decisions. It is important to review the policy carefully, maintain proper documentation, and raise the claim within the stipulated time to ensure a seamless claim experience.

If you are looking for an insurer that ensures hassle-free claim settlement, choose Bajaj General Insurance. We have a high claim settlement ratio, and we believe in maintaining great customer relations through our seamless services.

Frequently Asked Questions

How long does health insurance reimbursement take?

The time for processing a reimbursement claim can vary depending on the insurer. Typically, it takes around 15-30 days from the submission of all required documents.

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

Yes, most policies have a waiting period for certain treatments or pre-existing conditions. Check your policy document for detailed information.

How can I ensure my expenses fall within the maximum limit set by my policy?

Keep a track of your expenses during treatment and compare them with the sub-limits set by your policy. Always check the coverage for room rent, doctor’s fees, and other medical costs.

What expenses can be reimbursed?

Expenses such as hospitalisation costs, diagnostic tests, surgeries, and post-hospitalisation treatments are generally covered. Refer to your policy for detailed inclusions.

*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.