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What is a Reimbursement Claim in Health Insurance & How it Works?

Imagine this: you’ve faced a sudden medical emergency, paid hefty bills upfront, and now need to recover your expenses.

This is where a reimbursement claim steps in, acting as your financial safety net. Submitting bills, prescriptions, and medical reports seamlessly transforms your out-of-pocket expenses into reimbursed relief.

It's not just a claim; it's a promise that your health comes first—even in unexpected moments. 😁

Team Digit

Reimbursement Claim in Health Insurance
When Should You File a Claim?
Features and Benefits
Factors to Consider Before Filing
Frequently Asked Questions

Meaning of Reimbursement Claim in Health Insurance

A reimbursement claim is an official request for compensation or a refund for out-of-pocket medical expenses made by a policyholder to their health insurance policy provider.

In simple words, a Reimbursement Claim is a type of claim in which an insured must pay for medical costs and treatment out of their own pocket and later claim the bill from the insurance provider. For this kind of claim, the insured can visit any hospital for treatment, not necessarily the empanelled cashless hospital.

Let’s understand this with an example:

Shweta has a health insurance policy and resides in Delhi. She had to undergo a minor nerve surgery, for which she visited her family neurospecialists. Unfortunately, the hospital she chose was not empanelled with the insurance company. 😣

After treatment, she paid the treatment cost herself and kept all the essential documents, invoices and receipts. She filled out a reimbursement claim for the insurance company and after verification, her expenses were returned to her. 🙂

How Does the Reimbursement Claim Process Work?

The reimbursement claim process is simple: You go for treatment, you pay, we verify, and we pay you. However, the work is more complex than this! Let’s understand how a health insurance reimbursement claim works:

Step 1

Seek Treatment and Pay Bills: Receive medical treatment at any hospital you choose and pay all medical expenses, including consultation fees, room charges, medications, and procedures, out of pocket.

Step 2

Inform Your Insurance Provider: Notify your insurer about the hospitalization usually within 24-48 hours for emergency treatments and 3-4 days before planned treatments.

Step 3

Collect and Organize the Required Documents: Collect all necessary documents like hospital bills, discharge summaries, prescriptions, diagnostic reports, and a completed claim form.

Step 4

Submit the Claim: Compile all documents and submit them to the insurance company or the third-party administrator (TPA) within the timeline specified in your policy.

Step 5

Approval and Reimbursement: Once approved, the insurer reimburses the claim amount directly into your registered bank account.

When Should You File a Reimbursement Claim?

A reimbursement claim becomes necessary when you’ve paid for medical expenses out of pocket and must recover the costs from your insurer. This often happens when treatment is done at a non-network hospital in India where cashless facilities are unavailable.

Additionally, expenses such as pre and post-hospitalization costs, diagnostic tests, and outpatient treatments that aren’t covered under cashless claims may require reimbursement filing.

Let’s take different cases and understand which claim you should file in which situation:

Scenarios	Type of Expense	Type of Claim to File
You went for planned surgery in a network hospital where the insurer settles the bill directly with the hospital.	Hospitalisation	Cashless Claim
You had to undergo emergency surgery at a non-network hospital, where you had to pay the bills.	Hospitalisation	Reimbursement Claim
You needed an immediate hospitalisation due to an accident.	Accidental Hospitalisation	Cashless Claim (network hospital) and Reimbursement Claim (non-network hospital)
You underwent surgery in a network hospital in India, but your cashless claim was rejected due to missing documents.	Hospitalization	Reimbursement Claim
You had to undergo a consultation and lab tests weeks before and after getting hospitalised for a medical procedure.	Pre & Post Hospitalization	Reimbursement Claim
You had to visit a clinic weekly for skin allergy treatment without requiring hospitalisation.	OPD Expenses	Reimbursement Claim

Features and Benefits of a Reimbursement Claim in Health Insurance

No Location Constraints

You can visit your desired healthcare facilities and utilise your health insurance benefits. It can be any other hospital rather than an empanelled cashless hospital to help you avail yourself of your health insurance benefits.

Immediate Treatment

Before starting the treatment, you need not wait for the insurance provider's approval or other insurance-related procedures. You can receive immediate treatment at your desired hospital with a high state-of-the-art facility.

Flexibility in Claim Process

You can apply for a reimbursement claim as soon as your medical care is finished and the bills have been paid. This procedure removes delays and ensures a seamless and effective compensation experience.

Factors to Consider Before Filing a Reimbursement Claim

Medical reimbursement claims might be a good option, considering their flexibility in selecting the medical centre for treatment. We can choose any desirable hospital, not just the empanelled hospital.

However, while opting for a reimbursement claim or selecting a non-network hospital, one must consider a few points as listed below:

How to File a Reimbursement Claim?

If you wish to opt for a hospital of your choice that might not be empanelled with your insurance provider, you can use the Reimbursement Claim. You can avail yourself of the medical treatment first, settle the bills, and then apply for a reimbursement claim from your insurance provider. Let’s take Digit’s health insurance policy as an example. If you choose a non-network hospital for treatment, here are the steps you must follow to submit a reimbursement claim: