What is a reimbursement claim?

A reimbursement claim is a process where an employee pays for medical treatment out of pocket and later submits documents to get reimbursed by the insurer for eligible expenses. This differs from a cashless claim, where the insurer directly settles the bill at a network hospital.

Example: If an employee undergoes a surgery at a hospital that is not part of the insurer’s network, they can still raise a reimbursement claim and recover the approved expenses later.

When to opt for a reimbursement claim

• Treatment at a non-network hospital.
• Emergency hospitalization where cashless approval isn’t possible.
• Delays in pre-authorization for cashless treatment.
• Hospital infrastructure does not support cashless despite being empanelled.
• Lack of available network hospitals nearby.

Step-by-step guide to filing a reimbursement claim

1. Notify the insurer or TPA

Inform the insurer or TPA within 24-48 hours of admission. Some insurers allow post-discharge intimation for emergency cases, but earlier is always better.

2. Collect all original documents

Employees must gather every relevant document, such as:

• Hospital discharge summary
• Doctor’s prescriptions
• Diagnostic reports
• Original, itemized hospital bills
• Pharmacy bills
• Policy card and ID proof
• FIR/MLC report (if applicable)

3. Fill the reimbursement claim form

The employee must complete the form correctly (explained in detail below).

4. Submit the claim

Submit all documents, either online or via courier, to the insurer within the specified timeline (usually 7-15 days after discharge).

5. Track claim status

Most insurers provide online tracking, email updates, and SMS alerts.

How to fill a reimbursement claim form

Personal and policy details

• Employee name
  
• Policy number
  
• Corporate/company name
  
• Employee insurance ID

Hospitalization details

• Admission and discharge dates
  
• Hospital name and location
  
• Reason for hospitalization
  
• Whether it was an emergency or planned admission

Nature of illness or treatment

• Diagnosis
  
• Surgical details, if applicable
  
• Doctor’s recommended treatment

Bank details

• Account holder name
  
• Account number
  
• IFSC code
  
• Bank name

Declaration and signature

Tips for employees:

• Use clear handwriting (if offline)
  
• Avoid overwriting and corrections
  
• Double-check bank details
  
• Attach all required documents
  
• Keep photocopies of everything

Documents required for reimbursement claim

• Filled and signed reimbursement claim form
  
• Hospital discharge summary
  
• Medical reports and prescriptions
  
• Original bills and payment receipts
  
• Pharmacy bills
  
• Policy document or e-card
  
• Employee ID proof
  
• FIR/MLC report (for accidents)

How to track your claim status

• Insurer’s mobile app or portal
  
• TPA website
  
• Customer support helpline
  
• Email/SMS notifications

Can reimbursement health insurance claims be rejected?

Yes. Reimbursements undergo strict verification and may be rejected if requirements are not met.

Common reasons for reimbursement claim rejection

• Missing or incomplete documents
  
• Wrong or mismatched details in the reimbursement claim form
  
• Bills not in the required format
  
• Late submission (beyond insurer timelines)
  
• Treatments not covered under the policy
  
• Non-disclosure of pre-existing conditions (rare in group plans)
  
• Submitting photocopies instead of originals

Conclusion

Knowing how to file a reimbursement claim correctly helps employees access financial support even when using non-network hospitals. For HR teams, understanding the reimbursement claim process reduces confusion, avoids delays, and ensures employees get their claims approved smoothly. Accurate forms, complete documents, and timely submission make the biggest difference.

For a detailed overview of how cashless and reimbursement claims work, check out- Pazcare’s guide to the health insurance claim process.