Reimbursement Claim

What is a reimbursement claim?

A reimbursement claim is a health insurance claim in which the insured person pays for eligible medical treatment upfront and later asks the insurer to reimburse the covered amount. The insurer reviews the claim against the policy terms. If the treatment and expenses are covered, the insurer reimburses the eligible amount after accounting for applicable deductibles, exclusions, co-payments, sub-limits, or other policy conditions.

The amount reimbursed does not necessarily have to match the total hospital bill.

For example:

• Hospital bill: ₹75,000
• Eligible expenses under the policy: ₹68,000
• Applicable deductions: ₹5,000
• Amount reimbursed: ₹63,000

The actual calculation will depend on the employee's specific health insurance policy.

How does a reimbursement claim work?

1. Get the required treatment

The employee receives treatment at the hospital or healthcare provider and pays the applicable expenses. Before treatment, it is worth checking whether the hospital is part of the insurer's network and whether cashless treatment is available. However, the availability and eligibility of cashless treatment depend on the policy and the circumstances of the treatment.

2. Pay the medical expenses

For a reimbursement claim, the employee generally pays the hospital or healthcare provider first. Make sure you collect proper receipts for payments made. Keep the documents safely until the claim has been completely settled.

3. Collect the necessary documents

After treatment, collect the documents needed to support the claim.

These may include:

• Completed reimbursement claim form
• Hospital bills
• Payment receipts
• Discharge summary
• Doctor's prescriptions
• Diagnostic reports
• Pharmacy bills
• Investigation reports
• Relevant medical records
• Bank details, where required

The exact requirements can vary depending on the insurer, policy, and type of treatment.

4. Submit the reimbursement claim

Submit the completed claim form and supporting documents through the channel provided by your insurer, TPA, or employee  benefits platform. Depending on the insurer, this could be an online portal, mobile app, email, or another specified process.

5. The insurer reviews the claim

The insurer checks whether the treatment and expenses are covered under the policy.

It may review factors such as:

• Whether the person was covered when treatment took place
• Whether the treatment is covered
• Whether any waiting period applies
• Whether the expenses fall within policy limits
• Whether the documents support the claim
• Whether any exclusions apply

If additional information is required, the insurer may ask for it as part of the claim assessment.

6. The eligible amount is reimbursed

If the claim is approved, the insurer pays the eligible amount according to the policy terms. If the claim is partially approved, the insurer should communicate the applicable deductions or reasons for the amount that was not approved.

When can you file a reimbursement claim?

The circumstances in which reimbursement is available depend on the terms of the group health insurance policy. A reimbursement claim may be relevant when:

You receive treatment at a hospital where cashless treatment is not used

If cashless treatment is not available or is not used, you may have to pay the bill yourself and subsequently file a reimbursement claim, subject to the policy terms. IRDAI requires insurers to provide information on their websites about the claim settlement process, including the steps for reimbursement claims and applicable turnaround times.

Cashless treatment was not available at the time

In an emergency, an employee may not always be able to arrange cashless authorization before treatment. Depending on the policy and circumstances, the employee may later submit the expenses for reimbursement.

You paid eligible expenses yourself

There can also be situations where certain eligible medical expenses are paid directly by the employee and later claimed under the policy. The important point is that paying a medical bill does not automatically make it reimbursable. The expense still needs to meet the coverage conditions of the policy.

What documents are required for a reimbursement claim?

The exact list varies by insurer and policy, but employees may commonly be asked for:

Reimbursement claim form

This is the form used to provide information about the patient, treatment, hospitalization, expenses, and claim.

Hospital bills

These show the services provided and the amount charged by the hospital.

Payment receipts

These establish that the employee or patient actually paid the medical expenses.

Discharge summary

For hospitalization, the discharge summary generally records details such as the diagnosis, treatment provided, hospitalization period, and discharge instructions.

Doctor's prescriptions

These can help establish why medicines, investigations, consultations, or other treatment were required.

Diagnostic and investigation reports

Depending on the treatment, this may include blood tests, scans, pathology reports, or other diagnostic records.

Pharmacy bills

If medicines are covered under the policy, pharmacy bills may be required to support the claim.

Bank details

The insurer may require bank account information to process the reimbursement. The important thing is to check your policy or insurer's claim checklist rather than relying on a generic list.

IRDAI's guidance states that insurers should call for necessary claim documents together rather than asking for them in a piecemeal manner, except where fraud is suspected. It also states that documents not listed in the policy terms generally should not be treated as necessary, subject to the applicable rules.

How to file a reimbursement claim

The exact process depends on the insurer or TPA, but the usual options include:

• Insurer's website
• Mobile application
• TPA portal
• Physical document submission
• Employee benefits platform

If you are covered through a group health insurance policy, your HR or benefits team may also provide instructions on where and how to submit the claim.

Why can a reimbursement claim be rejected?

A reimbursement claim can be rejected for several reasons. Some common ones include:

The treatment is not covered

The policy may exclude a particular treatment, procedure, or expense.

The expense is outside the policy limits

A policy may have sub-limits or other restrictions on certain expenses.

Required documents are missing

If the insurer cannot verify the treatment or expense based on the submitted documents, it may ask for additional information or assess the claim accordingly.

A waiting period applies

Some treatments may be subject to waiting periods under the policy.

The claim does not meet policy conditions

Every health insurance policy has specific terms and conditions. A claim may be declined when the circumstances do not meet those requirements.

Incorrect or inconsistent information

Differences in names, dates, amounts, or other important details across documents can create issues during claim assessment.

A rejected claim does not necessarily mean the process ends there. If you believe a claim was incorrectly rejected, first read the rejection communication and the relevant policy condition. You can then provide clarification or additional documents where permitted and use the insurer's grievance process if you still disagree with the decision.

Give your employees a simpler way to manage group health insurance and get claims support when they need it.

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