Step-by-Step Guide to Reimbursement Claims in Health Insurance

• Having a health insurance policy can be beneficial when a medical emergency occurs. You can file a claim with your health insurance provider in such circumstances. After the claim is processed and approved, the insurance company can assist with the financial expenses for the treatment of the medical emergency. *

• The method to file a claim can vary between insurance providers. There are also two types of claims – cashless claims and reimbursement claims. In a cashless claim, the insurer manages the payment directly with the network hospital. In a reimbursement claim, the policyholder can select a hospital of their choice and pay for the medical expenses. They will be reimbursed by the insurer afterward.

• Claims are governed by the terms and conditions established in the health insurance policy.

Let us examine the reimbursement claim process of Bajaj Allianz General Insurance Company in detail.

How to File a Reimbursement Health Insurance Claim

• Keeping your care and comfort in consideration, we, at Bajaj Allianz General Insurance Company, have developed a straightforward, no-frills health insurance claim process. Here is the procedure, divided into different steps for clearer understanding:

1. Notify the insurance company

• We recognize that during a medical emergency, it may be challenging to contact the insurance company immediately. However, we encourage you to reach out as soon as you can. In cases of planned hospitalization, you can also notify us prior to admission, which will ease the burden on you during the hospitalization process.

2. Pay bills and gather documents

• Since you have chosen a reimbursement claim, you will need to pay the bills out of pocket for now. Make sure to keep each bill and invoice secure. Along with the bills, you will also need to gather the original hospitalisation-related documents. A list of documents required to file a health insurance claim is provided in a later section of the article.

3. Submit the claim form and documents

• Now, once you have completed the payment process on your end, you need to send the appropriate documents to the insurance company. You will also have to complete the claim form with the correct information. If you require assistance on How to fill Final Claim Form, you can refer to this resource to get the help you need.

4. Allow the insurance company to verify and inquire

• Based on the information you have provided, the insurance company will verify the claim. If additional information is required or there is a lack of certain documents, they will contact you. Once all requirements have been fulfilled, the insurance company will settle the claim within a specified timeframe.

• At Bajaj Allianz General Insurance Company, you can rely on us to start the health claim settlement process and issue the payment within 7-10 working days.

• Claims are governed by the terms and conditions set forth in the health insurance policy.
• Note: You can also submit a health insurance claim digitally. The reimbursement claim form can be obtained by visiting the insurance company’s website or by conducting a search.

Documents Needed for Reimbursement Health Insurance Claim

• In addition to the claim form, the documents necessary for the Mediclaim reimbursement procedure are as follows:
• Discharge summary of the patient (original)
• Hospital bill, including a detailed breakdown of the costs (original)
• Paid receipts (original)
• Lab and test reports
• Copies of invoices/ stickers/ barcodes in case of implants
• Initial consultation letter from a doctor
• KYC form
• NEFT form, completed and signed by the policyholder/ proposer

• If the insured individual has deceased during hospitalization, further documents, like the original death summary document and legal heir certificate may be required. Claims are governed by the terms and conditions specified in the health insurance policy.

Can a Health Insurance Claim be Denied?

• Yes, the insurance company has the ability to refuse your claim for several reasons. Generally, the claim may be declined if it does not fall under the insurance policy’s scope. Some specific reasons that may result in health insurance claim denial include:

• Treatment for a condition/ medical event not included in the health insurance plan.

• Omission or misrepresentation of a pertinent medical fact by the policyholder.

• Treatment and the resultant claim deemed unnecessary and unsupported/ fraudulent.

• Claim submitted during the waiting period for a specified or pre-existing illness as identified in the policy.

• A claim can be declined for numerous other reasons. To obtain a complete list of the exclusions, you should review the entire content of your health insurance policy document.

FAQs

What is a reimbursement claim in health insurance?

It’s a procedure to recuperate medical expenses from your insurer for treatments received at non-network hospitals by presenting bills and documents.

How do I file a reimbursement claim?

Inform your insurer, collect necessary documents, submit the claim form, and wait for approval for reimbursement.

What documents do I need for a reimbursement claim?

You will require original bills, discharge summary, prescriptions, diagnostic reports, a filled claim form, and identity proof.

How long does it take to get reimbursed?

It usually takes 15–30 days after all required documents have been submitted.

Can I claim reimbursement for non-network hospital treatments?

Yes, as long as the expenses are covered by your policy.