Knowledgebase:
Reimbursement Process for Health Insurance Policies
Posted by Deepak Mendiratta on 28 December 2020 01:05 PM
Health Insurance Reimbursement Claim (Mediclaim Policy)

We understand that you have a health claim to be filed. We will provide you with a detailed process below to get this money recovered and paid back to you.
A health insurance reimbursement claim can be either for the following -
  • Main Hospitalisation
  • Pre and Post Hospitalisation
Reimbursement claim process is mentioned below

Please read the claim form carefully before you start filling it up
  • Please note that the following fields are mandatory in a claim form
  • Policy Number (in case of Corporate policies, even if you don't have the policy number, thats fine, you can omit it
  • Cashless Identity Card number ( would be mentioned on your hard copy or E Card in case you have that)
  • Name of the Insured ( Primary Member) with addresses and contact details
  • Name of the Corporate & Employee code
  • Name of the Patient, date of birth and relationship with the employee
  • Tick on the type of claim, write, and date of admission and discharge, name, address and contact details of the hospital
  • Provide the details of illness / injury / disease
  • Provide the details of amount that is being claimed with breakup of bill numbers
  • All documents in original
  • Signature of the claimant along with place and date (this is mandatory)
Important Points -
  • All documents to be filed under the claim have to be in Originals
  • Once the claim form is filled you need to submit the claim form along with all mandatory documents.
  • Following original documents are mandatory to process a claim under reimbursements
  • Please note the hospital should a minimum of 15 beds. (Read Here for more details on Bed Requirement for it to be qualified to be eligible for claim payment under health insurance)
  • Copy of Hospital Registration Certificate with Registration number and number of beds certificate (This may not be required in case of larger hospital which are well known and in larger towns / cities )
  • Claim Form duly signed. This is absolutely mandatory
  • Copy of the Claim Intimation, if any ( If you are filing the main hospitalisation expenses for reimbursement, then you would have done the intimation of the claim in advance, as per your policy terms. Do attach a copy of that)
  • Hospital Main Bill with proper breakup of the expenses. Often there is a summary bill and then there is a bill which mentions all line item wise expenses. The insurer will need the detailed latter bill
  • Hospital Bill Payment Receipt for which the policyholder / claimant made the payment to the hospital. Do note that this receipt will need to be numbered.
  • Original Hospital Discharge Summary (which should clearly mention -
  • Patient name
  • Date of Admission
  • Date of Discharge
  • Age of the Patient
  • Final Diagnosis
  • Case Summary / History (On Examination), Course in Hospital, Line of Treatment, Advice at Discharge with signatures and stamp of treating doctor. This will be on the hospitals letter head
  • Others medical document that may be provided
  • Doctor’s Prescriptions. Often in non-emergency cases, the patient is first shown to the doctor n OPD basis, In such cases all doctors prescriptions will be needed
  • Copy of photo identity card of patient and employee
  • Pharmacy bills.
  • MLC Report & Police FIR, Alcoholic declaration in case of accidental cases particularly Road Traffic Accident (RTA)
  • Also in RTA Cases, detailed circumstances of the trauma with date, place and time. This is mandatory for reimbursement claim in case of an accident case.
  • All Investigation Films and Reports - ECG / CT / MR / USG / HPE or any other investigation reports. Obviously there will be no films in cases of blood investigations, urine / stool investigations or biopsy
  • Original cancelled cheque, with printed name, for the transfer of payment to your bank account. If you providing cancel cheque without printed name please submit the copy of passbook with bank attestation. Bank E-statement (In case your name as an employee is NOT printed on the cancelled Cheque)

The Insurer / TPA will take approximately 30 days to process the claim once all documents that they need are provided to them. Payment will be transferred directly to your bank account as per the bank details provided by you.
There are times when the TPA may request you to provide additional information when there is any shortfall / query in the documents submitted by you. Such could be either to ascertain / confirm that the treatment is aligned to the coverage under your health insurance cover or they may request for some cost breakup details etc. These, unforeseen and relatively few interventions, may delay the processing of your claim which will further delay the payment. Hence, you need to immediately furnish the documents requested by the Insurer / TPA to ensure speedy processing of your claim.

Do note there are some non-payable items which the Insurance Company will not be paying as part of a health insurance claim. These are generally for the test of HIV, consumable items such as syringe, gloves. You can see the details of such items here

Claim Intimation (Do note, this is an Important Clause )

You should intimate the TPA within 24 hours of hospitalisation in case of unplanned / emergency cases and before 48 hours of hospitalisation in case of planned treatments. This will be applicable for both cashless as well as reimbursement cases. This clause allows an insurer to depute an investigator, if they so wish

Please get in touch with us at any stage of your hospitalisation requirements. 

While our endeavour is to ensure that you are not inconvenienced on any count. Our role is to ensure that your case is presented accurately with the insurer / TPA and no delays or rejections occur unjustly. At PlanCover.com, we represent your interests above all else. Our commitment and actions are aligned to ensuring that the process is smooth for you.

Happy Heath to All

Team
PlanCover.com
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