3 December, 2023
Reimbursement in Health Insurance

A health insurance policy is an extremely useful policy that helps to cover the insured’s uncertain expenses arising from an illness or hospitalisation. It covers numerous expenses like:

  • Cost of medicines
  • Hospitalisation cost
  • Surgeries expenses
  • Doctor’s consultation cost and much more.

For any policy, the moment of truth arises when it comes to the insurance claim. An individual applies for a medical insurance policy to stay financially protected during medical emergencies or medical treatment. It is imperative for you to understand the reimbursement claim process so that you can rely on your insurance policy during uncertain circumstances. Keep scrolling through to know the details regarding the reimbursement in health insurance.

What is Reimbursement in Health Insurance?

The word “Reimbursement” refers to repayment to the person who has spent money. Reimbursement in health insurance is a claim settlement type wherein you pay for the medical expenses to avail yourself of the treatment, and later on, your insurer reimburses the amount that you had paid. It is an employer-funded, tax-advantaged health benefit plan through which organisations reimburse their employees for medical expenses. Healthcare reimbursement is a type of allowance that the insured can use for their medical expenses along with insurance premiums.

Often the health insurer or the government payer covers either all the cost or a part of your healthcare, depending upon your health plan. So, with reimbursement health insurance, you can stay financially secure even during uncertain times.

Under the claim reimbursement, the insured will initially pay for the treatment and will then follow the reimbursement claim process. When you file a claim reimbursement, you will have to produce the bills and show other details of money spent on hospitalisation and treatment. The insured will then verify all the expenses and will credit the amount to your bank account.

Features & Benefits of Reimbursement Health Insurance

One of the key features due to which reimbursement health plans have gained huge popularity is the flexibility of availing the medical treatment at the desired hospital. Here are some of the benefits of a reimbursement medical insurance policy:

  • During a medical emergency, you will not have to worry about locating the network hospital. Now, you can visit any hospital to avail the medical treatment and claim the money from your insurer later.
  • While getting the medical treatment, you need not go through any tiresome and time-consuming health-related procedures.
  • You can apply for the claim reimbursement from your insurer once the medical treatment is availed and bills are settled in the hospital. Thus, with a reimbursement insurance plan, you will not have to worry about your medical expenses.
  • You can avail the treatment from metropolitan hospitals at the best prices possible.
  • It allows the insured to choose the type of medical expenses they want to get reimbursed for. This helps to offer more freedom and flexibility to the insured in comparison to other health benefits.
  • Reimbursement health policy helps to improve the healthcare services quality offered to the policyholder as they can choose the hospital and services according to their needs and preference.
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How Does Reimbursement Health Insurance Work?

With a reimbursement medical insurance policy, you can get medical treatment at your preferred hospital. After the treatment, you will have to clear the hospital bills on your own and can later apply for a medical claim reimbursement by submitting the required documents and bills. The reimbursement process in health insurance is quite simple, and you can enjoy multiple advantages. There are numerous reliable insurance companies that offer a financial cushion to the policyholder in their time of need. Under this policy, you can visit any hospital according to your preference to avail the medical services.

Reimbursement Claim Settlement & Claim Process

If you want to opt for the hospital of your choice, you can apply for medical claim reimbursement. Below mentioned is the reimbursement claim process that you must know about:

  • The first and foremost step is that you must get in touch with your insurance company via their toll-free number and provide them details regarding the medical treatment and the hospital to which you are admitted to.
  • Avail the medical treatment at the desired hospital.
  • Once you have taken the medical service, make sure to settle the bills on your own.
  • After you have received the treatment and paid the bill, you can apply for the claim online.
  • You will have to share all the hospital-related expenses abnd bills.
  • Upon the verification of documents and scope of coverage by the insurance company, the amount will get transferred into your account.

The reimbursement claim process will help you get the treatment at your preferred hospital with all ease. Now that you know the health insurance reimbursement process, let’s dig deeper to know the details regarding what is covered under this and what documents you need to present to avail the benefits and the claim amount.

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What is Covered Under Reimbursement Health Insurance?

The reimbursement insurance policy covers all your hospitalisation costs, some of which are listed below:

  • Hospitalisation expenses
  • Pre and post-hospitalisation cost
  • The cost incurred due to daycare treatment
  • Critical Illness
  • Domiciliary hospitalisation expenses
  • OPD treatment 
  • Insured patient transportation via ambulance in case of a medical emergency

Documents Required for Reimbursement Claim

To claim reimbursement for the medical insurance policy, you will have to present various documents for the verification process. Duly filled and signed claim forms, medical certificates signed by the doctor, original discharge summary, all original hospital bills, prescriptions and pharmacy receipts, diagnostic reports, FIR or medico-Legal Certificate are some of the required documents.

Factors to Consider When Opting for Reimbursement Claim

The reimbursement in an insurance policy is a flexible option. You need not stick around a particular hospital to get medical treatment. But, before opting for such a claim, you must ensure that you have sufficient funds if you plan to take the medical treatment. In addition, you must keep track of all the documents and original bills for medical claim reimbursement, which is undoubtedly a tedious task. Also, during the claim process, you will have to submit the original documents so that the insurance company can verify the details.

Due to the tedious task of processing the validation of the documents, the time taken to settle the claim may be more. Therefore, it is extremely crucial for you to consider all these factors before applying for a reimbursement plan. If you find it easy to maintain a surplus in your account or can get into the document verification process, you must apply for a reimbursement insurance policy.

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  1. Is a cashless claim the same as a reimbursement claim?

No, under the cashless claim, your insurance company pays off your medical bills at the time of your discharge. However, in case of a reimbursement claim, you will have to pay your medical expenses and later claim the reimbursement at the time of your discharge from the hospital.

  1. How much time does it usually take to settle the insurance reimbursement claim?

The claim settlement ranges from one company to another. Various well-recognised companies offer claim settlement within 7 to 21 days of receipt of the claim-related documents.

  1. Is there any time frame to apply for the claim settlement after I have paid my medical bills?

Yes, after you have paid for the medical expenses, you must inform the insurance company within 30 days of the hospitalisation. However, it is advisable to apply for a claim as soon as possible. 

  1. When does a claim get rejected?

A medical insurance claim usually gets rejected if you make a claim during the waiting period or for an illness that is not covered by the policy. It even gets rejected if you make a false claim.

  1. What details should the policyholder provide to the insurance company at the time of intimation of the claim?

At the time of intimation of the claim, the following details must be provided to the company :

  • Policy Number
  • Name of the Policyholder/Patient
  • Name of the Insured Person in whose relation the Claim is being lodged
  • Nature of Illness / Injury
  • Name and address of the attending Medical Practitioner and Hospital
  • Date of Admission
  • Any other information as requested by us

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