Health Insurance Reimbursement: Types, Covered, Not Covered & Claim Process

By Okbima 01 Jul 2024
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Health insurance reimbursement helps people and doctors get money back for medical expenses. In India, there are two types of claims: cashless and reimbursement. Cashless means the insurance company pays directly, while reimbursement means you have to submit receipts for your expenses. Before making a reimbursement claim, you need to know what is covered, who is eligible, and what documents are needed. 

 

What Is Health Insurance Reimbursement?

Health insurance reimbursement is when an individual or healthcare provider submits a claim to their insurance company for medical services, treatments, or medications covered under their health insurance plan. The insurance company then pays back a portion of the costs incurred by the individual or healthcare provider for those services, based on the insurance plan's terms. Reimbursement amounts can vary depending on the type of insurance plan, the services provided, and the provider's contract with the insurance company.

 

Types Of Health Insurance Claims In India

There are mainly two types of health insurance claims in india such as cashless claims & reimbursement claims.

1. Cashless Claims

Cashless claims are a process in which an insurance policyholder can settle their claim without paying the expenses upfront. Instead, the insurance company directly settles the claim with the service provider, such as a hospital or repair shop, on behalf of the policyholder. 

This can be done through a network of authorized service providers that have agreements with the insurance company. Cashless claims help reduce the financial burden on policyholders and streamline the claim settlement process.

 

2. Reimbursement Claims

Reimbursement claims in health insurance are a process of submitting a request for payment of medical expenses incurred by an individual covered under a health insurance plan. This could include expenses such as doctor visits, prescription medications, hospital stays, and other medical services.

To file a reimbursement claim, the individual must submit a claim form along with supporting documentation, such as receipts or invoices, detailing the services received and the amount paid. The insurance company will review the claim and, if approved, will provide reimbursement for the covered expenses according to the terms of the insurance policy.

 

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What Is Covered In A Reimbursement Health Insurance?

In India, a reimbursement health insurance policy covers hospitalization expenses, daycare procedures, ambulance charges, organ donor expenses, etc.

  • Hospitalization expenses: This includes room rent, nursing charges, doctor's fees, diagnostics tests, medications, and other in-patient treatment expenses.

  • Daycare procedures: Coverage for medical procedures that do not require overnight hospitalization but are done in a hospital or daycare center.

  • Ambulance charges: Reimbursement for the cost of ambulance services used to transport the insured to a hospital for treatment.

  • Pre-existing conditions: Some policies may cover pre-existing conditions after a waiting period in health insurance.

  • Organ donor expenses: Coverage for medical expenses related to organ transplantation, including donor costs.

  • Alternative treatments: Some policies may cover alternative treatments like Ayurveda, Homeopathy, or Unani, among others.

  • Maternity expenses: Coverage for maternity-related expenses, including hospitalization, delivery, and post-natal care.

  • Critical illness coverage: Reimbursement for the treatment expenses of specified critical illnesses like cancer, heart attack, stroke, etc.

  • Room rent: Reimbursement for room rent expenses incurred during hospitalization, subject to the policy's terms and conditions.

 

What Is Not Covered In A Reimbursement Health Insurance?

In India, a reimbursement health insurance policy does not cover cosmetic procedures, alternative therapies, certain pre-existing conditions, etc.

  • Cosmetic procedures: Reimbursement health insurance does not cover cosmetic procedures such as Botox injections, rhinoplasty, etc.

  • Alternative therapies: Alternative therapies like acupuncture, chiropractic care, or naturopathy may not be covered by reimbursement health insurance.

  • 24/7 medications: Reimbursement health insurance may not cover the cost of 24/7 medications like pain relievers or cold medicine.

  • Experimental treatments: Experimental treatments that have not been proven effective or approved by the insurance provider may not be covered.

  • Certain pre-existing conditions: Some reimbursement health insurance plans may exclude coverage for certain pre-existing conditions, especially if the condition was known before purchasing the policy.

  • Routine check-ups and preventive care: While some reimbursement insurance plans may cover preventive care services like vaccinations or screenings, others may not cover routine check-ups or annual physicals.

  • Pregnancy and maternity care: Some reimbursement health insurance plans may not cover pregnancy-related expenses, including prenatal care, labor and delivery, and post-natal care.

  • Long-term care: Reimbursement health insurance does not cover long-term care services such as nursing home care or home health care.

 

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Factors You Should Consider Before Getting Reimbursement Claim

Before getting a reimbursement claim in India, there are many factors that you should consider such as eligibility, documentation, limits, approval process, etc.

  • Eligibility: Make sure that you are eligible for reimbursement as per your employer's policy or the terms of your insurance plan.

  • Documentation: Collect all the necessary documents needed to support your reimbursement claim, such as bills, receipts, medical reports, etc.

  • Limits: Check the reimbursement limits set by your employer or insurance provider to ensure that your claim amount falls within the eligible range.

  • Timely Submission: Ensure that you submit your reimbursement claim within the specified timeline to avoid any delays or rejections.

  • Approval Process: Understand the approval process for reimbursement claims and follow the necessary steps to streamline the process.

  • Review Policy Details: Understand the terms and conditions of your reimbursement policy to avoid any misunderstandings or discrepancies.

 

Claim Process For Health Insurance Reimbursement

The claim process for health insurance reimbursement is very simple and that is to submit proper documentation of medical expenses incurred to the insurance company for review and wait for approval.

  • Collect all the necessary documents: To file a claim for health insurance reimbursement, you will need to have all the necessary documents such as a claim form, medical bills, prescriptions, diagnostic reports, discharge summary, and any other relevant medical records.

  • Fill out the claim form: You will need to fill out a claim form provided by your insurance company. Make sure to accurately fill out all the required information, including details of the treatment received, the healthcare provider’s information, and the total amount incurred.

  • Submit the claim form and supporting documents: Once you have filled out the claim form and collected all the necessary documents, you can submit them to your insurance company. Some insurance companies allow you to submit claims online, while others may need you to send the documents via mail or in person.

  • Wait for processing: After you have submitted your claim, your insurance company will process it to determine the reimbursement amount.

  • Receive reimbursement: Once your claim has been processed and approved, you will receive the reimbursement amount either through a cheque, bank transfer, or direct deposit into your account.

  • Check for any discrepancies: It is important to carefully review the reimbursement amount to ensure that it is accurate. If you notice any discrepancies or have any questions, you should contact your insurance company for clarification.

 

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Documents Required For Health Insurance Reimbursement Claim

Documents required for health insurance reimbursement claims are completed claim forms, official receipts from the healthcare provider, prescription receipts, etc.

  • Completed claim form: The first document required for a health insurance reimbursement claim is a completed claim form. This form asks for details such as your personal information, the date and nature of the medical treatment, and the total amount you are claiming for reimbursement.

  • Official receipt from the healthcare provider: You will need to provide an official receipt or invoice from the healthcare provider that shows the date of service, the services provided, and the amount charged.

  • Medical reports and test results: If you received medical treatment or tests, you may need to submit medical reports and test results along with your claim. These documents provide further evidence of the treatment you received and the reason for submitting a claim.

  • Prescription receipts: If you are claiming reimbursement for prescription medications, you will need to provide receipts for the medications purchased.

  • Insurance policy details: You may be required to provide details of your health insurance policy, including your policy number and coverage details.

  • Authorization letter: Depending on your insurance provider, you may need to provide an authorization letter from your employer or the insurance company authorizing the reimbursement claim.

  • Any other relevant Documentation: Depending on the nature of your claim, you may need to provide any other relevant documentation such as referral letters, prior authorization forms, or any other supporting documents.

 

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Conclusion

In conclusion, health insurance reimbursement is crucial for covering medical expenses in India. Reimbursement claims cover various expenses, but not all are included. Understanding eligibility, documentation, and policy details is important before filing a claim. If you need any help, you can contact “Our Experts”.

 

FAQs

Reimbursement in insurance is the process of receiving payment from an insurance company for covered expenses incurred by the policyholder.

The time limit for health insurance reimbursement varies depending on the insurance carrier and policy, but it is within 30-60 days of the claim being submitted.

To file a reimbursement claim under health insurance, you will need to submit all relevant medical bills, receipts, and documentation to your insurance provider for review and processing.

It depends on the specific health insurance policy you have and the terms mentioned in your policy. Some health insurance policies may require a waiting period before you are eligible to make a claim, while others may have immediate coverage.

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