When Do You File a Reimbursement Claim?

A reimbursement claim is filed when you pay the hospital bill yourself and then seek repayment from the insurer. This happens when:

  • You are admitted to a non-network hospital (cashless is not available)
  • The cashless facility was not set up in time for an emergency admission
  • The insurer's network hospital was not accessible in your location
  • You chose a hospital not empanelled with your insurer

Reimbursement claims require careful documentation — missing even one document can delay or deny payment.

Complete Document Checklist for Reimbursement Claims

Mandatory for All Claims

  • Duly filled and signed claim form (download from insurer's website or app)
  • Original hospital discharge summary (signed by the treating doctor)
  • Original itemised hospital bill (must be stamped by hospital with their registration details)
  • Original payment receipts for all payments made to the hospital
  • All original doctor consultation notes and prescriptions during hospitalisation
  • All original diagnostic test reports (blood reports, X-rays, CT scans, MRI reports)
  • All original pharmacy bills (with corresponding doctor prescription for each bill)
  • Identity proof of the patient (Aadhaar, PAN, passport)
  • Cancelled cheque or bank account details (for direct NEFT transfer of claim)
  • Copy of insurance policy or health card

For Surgery Claims (Additional)

  • Surgeon's certificate specifying the procedure performed
  • Anaesthetist's certificate
  • OT notes (Operation Theatre notes)
  • Histopathology report (if biopsy performed)

For Accident Claims (Additional)

  • Medico-Legal Case (MLC) certificate from the hospital
  • FIR copy (if the accident involved a third party or motor vehicle)
  • Police report (for road accidents)

Pre-Hospitalisation and Post-Hospitalisation Claims

  • Doctor's referral letter recommending hospitalisation (for pre-hospitalisation)
  • All consultation receipts and prescriptions from the 30–60 days before/after hospitalisation
  • Pharmacy bills with prescriptions for this period

Step-by-Step Filing Process

  1. Intimate the insurer: Call the 24×7 helpline as soon as you are admitted (even to a non-network hospital). Most policies require intimation within 24–72 hours of admission.
  2. Collect documents at hospital: Before discharge, collect all original bills, reports, and the discharge summary. Ask specifically for the itemised bill — consolidated bills may be rejected.
  3. Organise and scan: Make clear photocopies of all documents and keep the originals. Scan or photograph everything for your records before submitting.
  4. Submit within the deadline: Most policies require submission within 15–30 days of discharge. Submit by courier with acknowledgement or via the insurer's online portal with scan uploads.
  5. Track the claim: Use the insurer's app, portal or helpline to track claim status. IRDAI mandates a decision within 30 days of receiving complete documents.

Common Reasons for Reimbursement Claim Rejection

  • Missing original bills (only photocopies submitted)
  • Bills without hospital stamp or registration number
  • Pharmacy bills without corresponding prescriptions
  • Consolidated (non-itemised) hospital bill
  • Claim filed beyond the 30-day submission deadline
  • Pre-authorisation not done for planned hospitalisation (required by some insurers even for reimbursement)
  • Treatment during waiting period

Timelines

  • Insurer must acknowledge receipt within 3 days
  • If additional documents are needed, insurer must request within 15 days
  • Decision must be communicated within 30 days of receiving complete documents
  • Payment must be credited within 7 days of claim approval

Tips for Faster Settlement

  • File online via the app where possible — paper submissions take longer
  • Call the helpline 7–10 days after submission to confirm all documents are received
  • If asked for additional documents, respond within the insurer's requested timeline to avoid claim lapse
  • Keep a case reference number for every interaction