How to file a claim for Reimbursement Mediclaim
  • Insights into Reimbursement Claim process
  • Points to note before filing a claim
  • Grounds for Rejection of Reimbursement Mediclaim
how to file claim for reimbursement of mediclaim insurance
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How to file a claim for Reimbursement Mediclaim

In case an emergency arises, you might have to rush to a nearby hospital for treatment. Even, when you have a planned surgery, you might want to avail the treatment at a hospital in your vicinity or near to where you reside. If the doctor treating you works at a specific hospital, you are likely to prefer it over others. That hospital may/ may not fall under the list of Network Hospitals of your Insurer.

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It may be possible that your Health Insurance Company's Network Hospital is not affiliated with your preferred hospital. Then your only choice would be to file a Reimbursement claim with your Health Insurance Company.

If this is your first time filing a claim for Reimbursement Mediclaim Insurance, you might come across questions like:

  • 'What is the procedure for obtaining a Reimbursement Claim Form?'
  • 'What is the best way to submit it?'
  • 'What documents are required?'
  • 'What is the deadline for submitting the form?'

In this article, we have shared insights on the entire procedure and its minute details.

What is a Reimbursement Claim?

You can file for Reimbursement Claim if you're admitted to/ getting treatment at a Non Network Hospital of the Insurer.

While opting for Reimbursement Claim, you need to primarily pay for your hospitalization on your own. Post submission of documents, verification & approval, the amount shall be transferred to your registered bank account.

While filing a Reimbursement Claim, be assured that your Health Insurance Policy covers expenses related to your treatment.

Features and Benefits of a Reimbursement Claim

Though reimbursement claims fall into the picture after you are done getting the treatment, these claims do offer some benefits to the policyholders. Read on to find out:

  • Flexibility These claims offer treatment options, even in the company's non-network hospitals, giving the policyholder a wide range of possibilities of receiving care in the hospital of his choice.
  • Wide Coverage A medical reimbursement claim covers a different cost, including doctor's fees, surgeries, medication, ambulances and much more. They cover almost all the expenses of the plan.
  • Timely Process After submitting the document the company settles the reimbursement claims very quickly, and the customer will be paid instantly into their bank account. So it is a time-bound process which takes less time to settle.
  • Convenience The mediclaim reimbursement process enables you to go on with your treatment without waiting for the insurer's approval.
  • Reliability All health insurance companies have designed a transparent reimbursement claim process. The claims can be filed online and you can even check the status of the claim on the official website of the company.

Factors You Should Consider Before Opting for a Reimbursement Claim:

  • Policy Coverage While choosing the reimbursement claims, the policyholder must read all terms and the limits of the policy coverage and ensure that the policy covers the necessary treatment and services.
  • Out of Pocket Expenses Customers must determine their ability to pay for the treatment costs as they will need to pay in advance before they can file for a reimbursement claim.
  • Documents Required The policyholder should acquire the required documentation in case they decide to seek care outside the company's network of hospitals. This will help to establish their claim in the future. Medical bills, reports, and hospital cash records are the documentation needed for mediclaim.
  • Do Read the Inclusions and Exclusions The policyholder must read the policy wording thoroughly as there are many facilities that are not covered under reimbursement claims. This will avoid future discrepancies in making a claim.

Steps Involved while Filing for a Reimbursement Claim

  • Intimate the companyYou must inform the company within the designated timeline.
  • Get your Documents ReadyYou must ensure that you have all original documents related to the treatment like Medical Bills, Doctor's Prescription, Diagnostic Reports, Pharmacy Bills etc.
  • Fill and Submit the Claim FormDuly signed & filled form must be submitted with other required documents.
  • Evaluation of Claim RequestAfter submission, the Insurance Company will evaluate the documents as per the Terms & Conditions of the policy.
  • Reimbursement Initiated by the CompanyOnce approved, the amount shall be transferred to the registered bank account.

When do I Need to Inform the Insurer about Reimbursement Claims?

In Case of Planned Hospitalization, the Insurer needs to be informed 2 days before the admission. In Case of Emergency Hospitalization, you must inform the Insurer within 24 hours of Hospitalization.

Documents Required for Filing Reimbursement Claim

  • Health Card Copy
  • Duly Filled Claim Form
  • Original Hospital Discharge Summary
  • Investigation Reports like scans, X-rays, blood reports, etc
  • Cash Receipts from Hospitals
  • If an accident happens, then FIR or medico-legal certificate(MLC)
  • Doctor's Consultation Papers and Pre-Admission Investigations
  • Copy of KYC documents
  • Contact Info, NEFT details
  • Invoices of pharmacy supported by respective prescriptions.

Points to Bear in Mind while Filing a Claim

Before getting a Mediclaim there are certain things that you should keep in mind:

Pre Existing Diseases (PED)

There is a certain Waiting Period that you have to surpass in order to avail compensation against them.

Renewal

It is important to renew your health policy on time to continue availing the benefits. If the policy is not renewed, you might not be able to file for a claim.

DayCare Treatments

Treatments which require less than 24 hours of hospitalisation are not covered.

Look into the Contract

Read the contract carefully to understand Terms & Conditions & additional steps (if any), which are required to file a claim.

How to Deal with a Health Insurance Claim Rejection?

Sometimes, your claim could be rejected due to multiple reasons, which must be rectified in order to avail of the benefits of Reimbursement Claim.

Claim Rejection Circumstances

  • Incorrect Information in the Claim Form
  • Claim Form not submitted within the timeline
  • Filing a claim for an exclusion

With the help of a third-party representative (TPA) and sufficient documentation, you can get your claim form corrected.

What if You Do Not Get a Reply from your Insurance Company?

If you haven't received a response from your Health Insurer within 30 days, you must contact your Insurance Ombudsman.

You can go for legal assistance in addition to addressing the Ombudsman's office. However, you must keep in mind that legal assistance might cost a lot.

To avoid rejection and the struggle that comes with it, it is preferable to submit accurately filled forms & proper documentation.

How to Track the Status of your Claim

You can check the status of your claim online. You can visit the official website of the Insurance Company and track the status by entering the relevant information.

How to file a claim for Reimbursement Mediclaim:FAQs

1. Can I file my Reimbursement Claim online?

Yes, you can file your Reimbursement claim online. Insurance companies offer a paperless claim submission facility that allows you to submit your Reimbursement Claims online in a hassle-free manner.

2. Do I need to submit KYC documents?

KYC documents are needed in case the claimed amount is more than or equal to INR 100K.

3. Should I keep original documents safe?

Yes, the original documents should be kept safe until the claim is settled.

4. How is a reimbursement claim different from a cashless claim?

When you get admitted to a company partnered Network Hospital, you can avail Cashless Claim facility, wherein your bills will be settled directly by the Insurance Company.

On the other hand, when you're getting treated at a Non Network Hospital, you can avail of the Reimbursement Treatment which effectively means getting reimbursed at a latter stage i.e. after the treatment.

5. How long does it take for a reimbursement claim to be processed?

It takes typically 15 to 30 days for a reimbursement claim to process, this totally depends upon the authenticity of the documents you submit.

6. Are reimbursement claims taxable?

No, health insurance reimbursement claims are generally not taxable.

7. What are the documents required for a reimbursement claim?

The common documents required for a reimbursement claim are a duly filled claim form, original hospital bills, prescriptions, diagnostic and lab reports, and an original discharge summary.

8. What are the documents required for reimbursement claims in the case of an accident?

In case of an accident, FIR will be the additional document required along with the other listed documents.

9. Even in the case of a reimbursement claim can I choose any hospital of my choice for treatment?

Yes, you have the freedom to select a healthcare facility of your choice in reimbursement claims.

10. Can I claim reimbursement in case of pre-existing conditions?

Yes, but all policies have waiting periods and exclusions for pre-existing ailments. Do check the waiting period duration before buying the plan.

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