Health Insurance Reimbursement Claims: Complete Guide

When you receive treatment at a non-network hospital, or when cashless authorization is not possible, you pay the hospital bill yourself and file a reimbursement claim with your insurer afterward. The process is more paperwork-intensive than cashless claims, but when done correctly, your insurer will reimburse the covered amount. Here is everything you need to know.

When Do You File a Reimbursement Claim?

  • Treatment at a non-network hospital
  • Emergency admission where cashless authorization could not be obtained in time
  • Cashless authorization was denied and you chose to proceed with treatment
  • Treatment in a city where no network hospital is available
  • Pre and post-hospitalization expenses (always reimbursed, never cashless)

Documents Required for Reimbursement Claim

Primary Documents

  • Duly filled and signed claim form (download from insurer website)
  • Original hospital discharge summary
  • All original hospital bills with itemized breakdowns
  • All original payment receipts
  • Doctor's consultation prescriptions and notes
  • All diagnostic test reports (blood work, X-rays, MRI, CT scans etc.)
  • Operation notes / surgical notes (for surgical procedures)
  • Pharmacy bills (originals with prescriptions)

Identity and Policy Documents

  • Copy of health insurance policy / e-insurance account
  • Copy of health card
  • Cancelled cheque or bank account details for NEFT transfer
  • Photo ID and address proof of the insured patient

For Pre-Hospitalization Claims

  • Treating doctor's prescription recommending the diagnostic tests
  • All diagnostic and consultation bills from the 30–60 days before admission

For Post-Hospitalization Claims

  • Discharge summary indicating follow-up care
  • All bills from follow-up consultations and pharmacy within the covered post-hospitalization period

Step-by-Step Reimbursement Process

Step 1: Notify Your Insurer

Inform your insurer within 24–48 hours of hospitalization (even for reimbursement claims). Many policy documents require this notification — missing it may lead to a delayed settlement or deduction.

Step 2: Collect All Documents at Discharge

Before leaving the hospital, collect every original document. Ask for itemized bills rather than summary bills — the insurer needs to see each expense line. Request duplicate copies of all reports before leaving, as originals must be submitted.

Step 3: Submit the Claim Within the Deadline

Most insurers require claim submission within 15–30 days of discharge. Some plans allow up to 90 days. Check your policy document. Late submission can lead to rejection.

Submit via insurer's online portal (fastest), registered post, or at the insurer's branch office. Always get an acknowledgement with a claim reference number.

Step 4: Track the Claim

Once submitted, you can track your claim status online or via the insurer helpline using your claim reference number. The insurer must settle claims within 30 days of receiving all documents.

Step 5: Receive Settlement

Payment is made directly to your bank account via NEFT/RTGS. You will receive a settlement advice letter detailing what was paid, any deductions made and the reasons for any partial payment.

Tips to Avoid Claim Rejection

  1. Never submit photocopies as originals — originals are mandatory
  2. Ensure doctor signatures are on all relevant documents
  3. Match names exactly — discrepancies between policy, ID and hospital documents cause delays
  4. Submit complete claims — missing documents are the primary reason for delays
  5. Keep personal copies of everything you submit

If Your Claim is Partially Paid or Rejected

If the settlement is less than expected, request a detailed claim settlement advice to understand every deduction. If you believe a rejection is unjustified, write a formal complaint to the insurer's grievance cell. If unresolved within 15 days, escalate to IRDAI's IGMS portal or approach the Insurance Ombudsman.