Mr Sharma wants to purchase health insurance plans for the family.
Ever cautious, he carefully reviews the policy documents. Upon reading, he learns about two claim settlement options: cashless and reimbursement health insurance. Since he has used it before, he knows the meaning of cashless claims but is curious to understand how reimbursement works in health insurance.
Let’s explore the concept of reimbursement claims to help you make an informed decision about your family’s health coverage.
What is Reimbursement in Health Insurance?
Reimbursement from health insurance refers to the process where the policyholder pays for the medical expenses upfront and later gets repaid by the insurance company.
In cashless health insurance, the insurer directly settles the bills with the hospital. However, for the reimbursement type of claim, you must bear the initial cost of the treatment. You then have to file an application for medical bill reimbursement with the insurance company to recover eligible expenses.
How to Raise Medical Reimbursement Claims?
Raising a reimbursement claim involves several steps, including:
Step 1: Notify your insurance provider about the hospitalisation. You generally have to inform your insurance Third Party Administrator (TPA) within 3 days of planned procedures or 24 hours for emergencies. It is necessary to initiate the claim reimbursement process.
Step 2: Avail the necessary treatment at your chosen hospital and settle the medical bills.
Step 3: Collect all required documents, such as hospital bills, discharge summary, medical certificates, prescriptions, lab reports, and FIR (if applicable).
Step 4: Obtain the form for reimbursement of medical claims from your insurer and fill it out accurately and completely. Make sure all the required information is provided to avoid rejection of your claim.
Step 5: Submit the completed claim form along with the required documents to your insurance company. You can do the claim reimbursement process online, by mail, or by visiting their office.
Step 6: Follow up on your claim status. If there are any delays or discrepancies, you can contact your insurer and resolve the issues promptly.
What are the Documents Required for Reimbursement in Health Insurance Plans?
While filing an application for medical reimbursement, you will need to submit:
- Duly filled and signed form for reimbursement of medical claims
- A copy of health insurance plans
- Hospital bills
- Discharge summary
- Medical certificates
- Prescriptions and bills
- Diagnostic/lab reports and their bills
- FIR in case of an accident
What are the Benefits of Health Insurance and Reimbursement?
Reimbursement from health insurance gives you the freedom to choose where and how you get medical care.
Here’s what that means:
- No network restrictions: You can go to any hospital you want, not just those your insurer approves.
- Complete control: You decide when and where to get treatment without worrying about insurance paperwork.
- Simple claims: After your treatment, you pay the bills and then submit a claim to your insurance company for reimbursement.
What is Covered in Reimbursement Health Insurance?
The coverage under cashless health insurance and reimbursement are similar. It includes:
- Hospitalisation expenses, including doctor’s fees, room rent charges, surgery expenses, medicines costs, and more
- Pre and post-hospitalisation expenses
- Daycare treatments
- Critical illnesses
- Maternity expenses (subject to policy terms)
- OPD expenses (subject to policy terms)
- Ambulance services (subject to policy terms)
What are the Factors You Should Consider During Medical Reimbursement Claims?
Getting reimbursed for your expenses can be a smooth process if you follow these steps:
- Understanding Your Coverage
Before submitting a reimbursement claim, carefully review your insurance policy or company guidelines. Know which expenses are covered and ensure your claims align with these categories. A clear understanding of your coverage will facilitate a smooth claims process.
- Checking Costs
Calculate the total cost of your expenses and compare it to the maximum reimbursement limit set by your policy or company. Exceeding the limit might lead to out-of-pocket expenses.
- Identifying Exclusions and Wait Periods
Review your health insurance plan policy for any exclusions and waiting periods. Certain expenses, such as elective cosmetic procedures, may not be eligible for reimbursement. On the other hand, certain costs may not be eligible for reimbursement during the waiting period. Plan accordingly.
- Managing Finances
Be prepared to cover expenses upfront, as the reimbursement claim process may take time. Effective financial planning helps manage cash flow until then.
If you carefully consider these factors, you can increase your chances of successful reimbursement claims and minimise issues.
While cashless health insurance is convenient, a reimbursement claim offers flexibility and control. The choice between the two depends on individual preferences and circumstances. By understanding the process for the application for medical bill reimbursement and carefully considering the factors involved, you can make an informed decision that best suits your needs.
Generali Central not only makes the claim process simple but also offers a range of health insurance plans for the family to suit your different needs. Explore the DIY Health Insurance, FG Health Absolute, FG Health Elite plans and Health Vital to find a policy that provides comprehensive coverage and a hassle-free claim process. With Generali Central by your side, you can focus on recovery while we take care of the financial aspects of your healthcare journey.
