File a Reimbursement Claim in Health Insurance

In case of planned or emergency hospitalisation, you may want to go to a hospital that’s in your vicinity. If the doctor who’s been treating you works at a particular hospital, chances are you would prefer that one over others.

In case of planned or emergency hospitalisation, you may want to go to a hospital that’s in your vicinity. If the doctor who’s been treating you works at a particular hospital, chances are you would prefer that one over others. Now, it may be possible that your health insurance company's hospital network doesn't cover your preferred hospital. Then, the only option you would have at hand is to make a reimbursement claim on your health insurance.

You might have too many doubts about a reimbursement claim that range from what is a reimbursement claim to what you can do to ensure a smooth and speedy settlement of your reimbursement claim. Hence, here we are to help you get acquainted with its complete process and further understand its intricacies.

When can you file a health insurance reimbursement claim?

In case of planned hospitalisation, you can inform us two days before admission, and in case of emergency hospitalisation, you need to inform us within 24 hours of hospitalisation.

Steps to raise a reimbursement health insurance claim

Unlike a cashless claim, you have to take the initiative when it comes to making a reimbursement claim. Here are the steps involved in a reimbursement claim process under our health insurance.

• Step 1: You intimate the claim

You can call our 24x7 toll-free number 1800 2666 or SMS ‘HEALTHCLAIM’ to 575758 (charge – ₹3 per SMS) or email us at ihealthcare@icicilombard.com to inform us about your hospitalization.

• Step 2: You get your papers ready

Once you have made the payment at the hospital, arrange all the documents chronologically. Start from the original bills for doctor’s consultation, X-ray, and other medical expenses to your discharge summary, medical reports, and hospital bill. With us, you can also include the bills of your medical expenses 30 days before hospitalisation and 60 days after.

• Step 3: You fill out & submit the claim form

Next, you’ll have to download the claim form from our website. Take a print, fill in the details in sections A, C, and D. Section B needs to be filled in by your treating doctor or the hospital. After that, sign on the claim form and also get it signed by your treating doctor.

• Step 4: We go through your claim request

Once you successfully submit all the documents, we’ll go through your claim request. Your claim can either be approved or turned down as per your policy coverage. There may also be a case where we ask for more documents from you to process your claim faster.

Till then you can track your claim status with your claim number on our website. If your claim is approved, we will transfer the claim amount into your bank account. If your claim is turned down, we’ll convey the reason for declining it.

Documents required for reimbursement health insurance claim

You will need to submit the claim along with the documents listed below. Those marked with an “*” are mandatory, and the rest will depend upon your claim request.

• Duly filled claim form*
• Original discharge summary/daycare summary*
• Original final hospital bill and other bills if any*
• Original payment receipts and other receipts supporting bills*
• Original investigation reports (Including ECG/ CT/ MRI/ USG/ HPE)*
• Original pharmacy bills*
• Original implant sticker/invoice
• Photocopy of doctor’s prescriptions*
• Photocopy of the consultation paper
• Photocopy of age proof (Driving license/ PAN card/ Passport/ Aadhar card)*
• Photocopy of indoor case paper
• EFT (Copy of cancelled cheque/self-attested ID poof/Bank-attested copy of passbook with IFSC code)*
• KYC (Copy of ID proof, Residence proof, & 2 passport-size photos) if the total claimed amount is more than ₹1 lakh

Things to keep in mind while filing a reimbursement claim in health insurance

To ensure you have a smooth and speedy reimbursement claim process, follow the below checklist:

• Check your hospital bill before you sign and pay it for any errors or unexplained extra charges.
• Collect all your receipts, reports and relevant documents from the hospital at the time of discharge.
• Also, collect any bills for medical expenses incurred 30 days before and 60 days after hospitalisation.
• Don’t forget to submit the mandatory documents along with other necessary proofs.
• Take time out to go through the policy inclusions and exclusions when you make a reimbursement claim to avoid any confusion at a later stage.

FAQs

1. What is a reimbursement claim?

In a reimbursement claim, you pay the hospitalisation expenses from your pocket, and the health insurance company later pays that amount to you, provided you submit all the necessary documents. You will have to apply for a reimbursement claim only if you choose to get your treatment done at a hospital which is not a part of your health insurance company’s hospital network or if you miss opting for a cashless claim.

2. How is a reimbursement claim different than a cashless claim?

A reimbursement claim can take longer to process than a cashless claim. For a reimbursement claim, you need to ensure you collect and submit all the documents and bills related to your hospitalisation. On the other hand, in a cashless claim, the empanelled hospital will do the job of sending your documents and bills to the insurance company, and the claim will be settled with them directly.

In a reimbursement claim, you have to wait till you get your money reimbursed from the insurance company, whereas in a cashless claim, the insurance company will pay it straight to the hospital. You will only have to bear the expenses that are excluded from your policy or are over your insured sum.

Since your insurance company does not have a tie-up with the hospital, your reimbursement claim will be thoroughly investigated. This may further delay your claim settlement. Cashless claims tend to get settled faster and in a hassle-free manner.

3. How long does a reimbursement claim take to process?

A Reimbursement claims are typically processed within 15–30 days after submission of all required documents.

4. Can I file a reimbursement claim for treatment at any hospital?

A Yes, you can file a reimbursement claim for treatments received at any hospital, regardless of whether it's part of your insurer's network, provided the treatment is covered under your policy.

5. What to do when my insurance claim is denied?

A If your claim is denied, review the insurer's reasons for denial, address any discrepancies or missing information, and consider appealing the decision if you believe it was unjustified.

Conclusion

Filing a reimbursement claim under your health insurance involves a series of well-defined steps. While making a reimbursement claim, you need to be careful about the coverage of your treatment and related expenses, especially under the health insurance policy for family. Your health insurance company can turn down your claim if your policy doesn't cover them.

Timely notifying your insurer, diligently collecting and submitting the necessary documents, and following the specified timelines are simple steps that save time later and ensure that the claim process is smooth. Always go through the documents to understand your policy's terms and maintain clear communication with your insurance provider to address any issues that may arise during the claim process.

Disclaimer: The information provided in this blog is for educational and informational purposes only. It is not intended as a substitute for professional advice, diagnosis, or treatment. Please consult your general physician or another certified medical professional for any questions regarding a medical condition. Relying on any information provided in this blog is solely at your own risk, and ICICI Lombard is not responsible for any effects or consequences resulting from the use of the information shared.