How does a reimbursement claim different from a cashless claim?

Under a reimbursement claim, you will first have to settle the hospitalisation bills with the non-network or network hospital where you have received your treatment. Submit all your claim documents to the TPA Within 15 days of being discharged and the insurer will settle the claim as per policy coverage.

How much time does it take to settle my health insurance reimbursement claim?

Settling a reimbursement claim can take some time since you will need to ensure that all your mandatory documents have been submitted to your insurance provider. After the process is completed at your end, your TPA will verify all the documents and then settle the claim within 30 days of having received the entire set of documents.

When can I inform my TPA of my hospitalisation?

You or your family can inform your TPA about your hospitalisation within two days of being admitted to the hospital.

When does a claim get rejected?

There are different reasons why a reimbursement health insurance claim can get rejected. Some of the most important ones are: Submission of incomplete or wrong documents. Non-disclosure of pre-existing diseases. Not submitting all the documents within the recommended timeline. Expenses incurred towards ailment falling under general exclusions.

Are Reimbursement treatments available at any hospital?

Yes, it is available at Network and Non- Network hospital.

Does Reimbursement health insurance have any exclusions?

Yes, when availing of Reimbursement health insurance, always read the list of exclusions under the policy. This list contains all the diseases, illnesses and conditions that are not covered under your insurance policy. Hence, when you file a claim for a disease/condition listed under the exclusions, your claim can be rejected.

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Reimbursement Claims

Reimbursement claims are a type of health insurance claim wherein during hospitalization, you pay for your hospital bills and later, post discharge contact your insurer / TPA to get your hospital Expenses reimbursed.

Table of Content

What Is Reimbursement Claim in Health Insurance?
Features and Benefits of a Reimbursement Claim
How To initiate a Reimbursement claim with TATA AIA?
Documents Required for Reimbursement of Health Insurance Claim

What are the Common Reasons for Health Insurance Claim Rejection?
Things to Keep in Mind While Filing a Health Insurance Reimbursement Claim
Frequently Asked Questions about Reimbursement Claims in Health Insurance

What Is Reimbursement Claim in Health Insurance?

Reimbursement claims are insurance claims wherein you pay for your hospital bills after your treatment and then submit the relevant documents to your insurance provider for a pay out as per the policy coverage.

Be it a planned hospitalisation or a last-minute medical emergency, hospital bills can involve a lot of expenditure. If you have health insurance, which is essential today, filing a reimbursement claim on your policy is very simple but we encourage you to avail the cashless facility to avoid huge out of pocket expenses which can be difficult to manage during hospitalisation.

Features and Benefits of a Reimbursement Claim
Below are some of the key features of a reimbursement claim:
- The major benefit of filing a reimbursement claim is that you can opt to receive treatment at a hospital of your choice. Therefore, you do not have to specifically choose a network hospital associated with your insurance provider.
- You can select any hospital that is known to you or your family or is in close proximity to your residence.
- You or your family do not need to worry about the reimbursement claim process during the treatment, as the documents must be submitted only after the treatment is complete.
- You will be given adequate time to file the Reimbursement claim after you get discharged from the hospital.

How to Initiate a Reimbursement Claim with Tata AIA?

These are the steps you can follow to file a reimbursement claim:

01.
Contact your insurer authorized TPA within 2 days of being admitted to the hospital. This is also applicable if your family member covered under the policy is hospitalised.
02.
Upload all the mandatory documents on TPA portal for further processing within 30 days of discharge. All the required documents should be self-attested.
03.
TPA will then help you submit the soft copies of your documents in case any assistance required.
04.
In case of any additional document required then TPA will communicate directly to you or your family member
05.
If all the documents suffice, then TPA will co-ordinate with the insurer for settlement of amount.

Documents Required for Reimbursement of Health Insurance Claim

Below is the indicative list.

Duly Filled and Signed Cashless Claim form
Discharge Summary
Medical Records (Optional Documents may be asked on need basis: Indoor case papers, OT notes etc.)
Hospital Main Bill
Hospital Main Bill with breakup
Pharmacy Bills with Prescriptions (except hospital supply)
Consultation & Investigation Papers
Digital Images/CDs of the Investigation Procedures (if required)
KYC (Photo ID Card) Bank Details with Cancelled Cheque

There are some more documents that will be needed only in specific cases, such as:

In case of an accident or involvement of police- MLC/FIR Report
In case of death or disability- Post Mortem Report, Death Certificate or Disability Certificate Invoice/Sticker (If applicable)
Attending Physician Certificate (If applicable)

What are the Common Reasons for Reimbursement Health Insurance Claim Rejection?

These are some of the main claim rejection reasons that you should be aware of while filing a cashless claim:
Claims During the Waiting Period

There may be a waiting period for certain risks and diseases covered under the policy. During this waiting period, if you are affected by any such condition or disease, you cannot file a successful Reimbursement claim till the period is over.

Claims on Exclusions

Your insurance policy will have a list of exclusions or risks, diseases and illnesses not covered under the plan. Hence, you cannot file a reimbursement claim to get treatment for any of the excluded diseases.

Withholding Information

If you have a pre-existing medical condition or a medical history, be sure to inform your insurance provider. Withholding this information can be risky for you as your insurance plan may not cover some illnesses and conditions.

Giving False Information

Mentioning wrong information regarding your or your family’s medical history, age, or income details for lower premium benefits can also get your cashless claim rejected. Your insurer can also choose to terminate your coverage.

Lapsed Policy

A lapsed, expired, or invalid policy is a major cause of health insurance claim rejection. If your policy coverage is inactive your claim can be rejected.

How to Avoid Health Insurance Claims Rejection?

These are some important tips through which you can avoid a health insurance claim rejection:

If you are suffering from a pre-existing illness or condition, be sure to mention this to your insurance provider before purchasing the policy. That way, if you need to be hospitalised or treated due to your condition, the insurer can ensure you receive adequate coverage.
Inform your TPA if you are being admitted to the hospital for a planned or emergency treatment. The Reimbursement claim procedure starts soon after your TPA has been informed, which helps them settle your claim as required without any hassles or delays.
Your policy document has all the details of the health insurance claim and policy coverages, Waiting period, General Exclusions. As soon as you get this document and before you file a claim, read all the terms and conditions carefully to avoid rejection of claims.
Ensure all documents are in place while filing the claim. Although TPA does not require extensive documentation for a Reimbursement claim, a list of essential and correct documents must be submitted so that your claim can be settled on time and without any issues.

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Frequently Asked Questions

Frequently Asked Questions

How does a reimbursement claim different from a cashless claim?

Under a reimbursement claim, you will first have to settle the hospitalisation bills with the non-network or network hospital where you have received your treatment. Submit all your claim documents to the TPA Within 15 days of being discharged and the insurer will settle the claim as per policy coverage.
How much time does it take to settle my health insurance reimbursement claim?

Settling a reimbursement claim can take some time since you will need to ensure that all your mandatory documents have been submitted to your insurance provider. After the process is completed at your end, your TPA will verify all the documents and then settle the claim within 30 days of having received the entire set of documents.
When can I inform my TPA of my hospitalisation?

You or your family can inform your TPA about your hospitalisation within two days of being admitted to the hospital.
When does a claim get rejected?
There are different reasons why a reimbursement health insurance claim can get rejected. Some of the most important ones are:
- Submission of incomplete or wrong documents.
- Non-disclosure of pre-existing diseases.
- Not submitting all the documents within the recommended timeline.
- Expenses incurred towards ailment falling under general exclusions.
Are Reimbursement treatments available at any hospital?

Yes, it is available at Network and Non- Network hospital.
Does Reimbursement health insurance have any exclusions?

Yes, when availing of Reimbursement health insurance, always read the list of exclusions under the policy. This list contains all the diseases, illnesses and conditions that are not covered under your insurance policy. Hence, when you file a claim for a disease/condition listed under the exclusions, your claim can be rejected.