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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. 😁
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. 🙂
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:
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.
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.
Collect and Organize the Required Documents: Collect all necessary documents like hospital bills, discharge summaries, prescriptions, diagnostic reports, and a completed claim form.
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.
Approval and Reimbursement: Once approved, the insurer reimburses the claim amount directly into your registered bank account.
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:
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.
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.
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.
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:
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:
Download the Digit Insurance App or file a health insurance claim option on the website.
Login and click on the "Health Claim Filing" option on the home page.
Select the type of claim you want to file from your active policies.
Fill out the Policy Details such as name, relationship with the policyholder, mobile number, etc.
Give a few details about the illness, such as the starting date of the symptoms, the first consultation date, the consultation hospital, etc.
Upload Documents such as the bill, discharge summary, test reports, valid ID proof, etc.
Although the exhaustive list might differ across insurance providers, here is a list of the most common documents required for a Reimbursement Claim:
There are some reasons why claims can be rejected. It can either be because of documentation or false information. Let’s discuss the common reasons why your claim can be rejected:
Don't freak out if your reimbursement claim is denied. You can re-apply for a claim if the claim is rejected because of documentation. Here are some ways of how you can deal with claim rejections with the following actions:
You might have understood by now that reimbursement claims in health insurance offer a reliable solution for managing medical expenses when cashless facilities aren’t an option.
Understanding the process and ensuring all required documentation is in place can help you easily reclaim your financial outlays. This is crucial to ensuring comprehensive health coverage, giving you peace of mind and allowing you to focus on what truly matters—your recovery and well-being.
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Disclaimer #1: *Customer can choose options at the time of availing insurance. Premium amount may vary accordingly. Insured is required to disclose any pre-existing condition or on going treatment before policy issuance in the proposal form.
Disclaimer #2: This information is added only for informative purposes and collected from different sources across the Internet. Digit Insurance is not promoting or recommending anything here. Please verify the information before making any decisions.
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