Reimbursement Claim in Health Insurance: Check Details

Claiming for reimbursement of mediclaim insurance would be tedious if you are doing it for the first time. How to get the reimbursement claim form? How to submit it? What documents are required? Within how many days should the form be submitted? A lot of questions may boggle your mind when it comes to filing a reimbursement claim after getting discharged from the hospital. However, you should not worry. Just read this article and you will get the solutions on how to file a reimbursement claim.

What is Reimbursement Claim?

When you buy health insurance in India, the insurance company lets you enjoy Cashless Claim and Reimbursement Claim benefits. The cashless claim is filed on getting treatment at network hospitals whereas the reimbursement claim is filed when you don’t get medical treatment in a network hospital i.e. a hospital that is not in the panel of the insurance company. You pay all hospital bills and other expenses related to treatment from your pocket. To get these expenses reimbursed, you need to file a reimbursement claim.

How to File a Reimbursement Claim?

Filing a health insurance reimbursement claim is not daunting. The process is very simple. Follow these steps:

• In case of planned treatment, inform your insurer about the treatment within the stipulated time (the exact time is given in the policy wording).
• In case of an emergency case, the intimation should be given to the insurance provider after being admitted (refer to policy wording to know the period).
• Get the treatment and pay the hospital bills yourself.
• Collect documents from the hospital such as investigation reports, final discharge summary, pharmacy bills, hospital bills, receipts, indoor case papers, valid ID proof, treating doctor’s report, and original consultation notes.
• Ask the insurer to email you the reimbursement claim form or download it from the official website of the insurance company. You can also contact InsuranceDekho for the same.
• All the documents should have a signature, cost price, patient’s name, document number, and serial number.
• Get the form signed by the policyholder and the treating consultant.
• The documents and the claim form should have the official hospital seal.
• Attach the Xerox copy of your health care and medical documents to the claim form.
• Send all the documents by courier to the address specified by the insurance company.

Note: Before sending the documents, review all the documents carefully. And also make sure you make copies of all the documents and claim forms for future reference. If any documents are missing, the claim may be rejected or the insurer may ask you to submit those documents as soon as possible.

In case, you are being provided medical insurance by your employer, read along to know tax benefits to an employee on reimbursement claims.

Eligibility Criteria for Employee Reimbursement Claim Process

The Reimbursement Claim eligibility criteria is mentioned below:

• An employee must have spent the money only on medical treatment expenses.
• The treatment amount must have been spent on the employee or their family members including spouse, children, parents or siblings, and other dependents.
• The employer must reimburse the specified amount, which is not more than Rs. 15,000 in a financial year.

Please note that the tax exemption is available only on the actual expenses on medical bills that an employee has spent. The bills could be the ones received from any of the pharmacies or treatment taken in public or private hospitals and clinics.

Documents needed for Reimbursement Claim Submission

You need the following documents in hand to file for reimbursement claim:

• Health Card Copy
• Hospital Discharge Summary (Original)
• Duly filled claim form
• Investigation Reports( like scans, X-rays, blood report, etc)
• Case receipts from hospitals or chemists
• If an accident happens, then FIR or medico-legal certificate(MLC)
• Doctor’s Consultation papers and pre-admission investigations
• Copy of KYC documents
• Contact Info, NEFT details
• Invoices of pharmacy supported by respective prescriptions.

Key Things About an Employee Medical Reimbursement

Every employee looking forward to claiming medical reimbursement should note a few points including: 

1. A medical reimbursement claim cannot be made for the previous financial year. 

2. There does not exist any kind of maximum limit regarding reimbursements related to medical expenses undergone at hospitals that are maintained by the employer. The same applies to medical expenses undergone at hospitals approved under health schemes by the Central Government or Government authorities.

3. There is a big difference between medical reimbursement and medical allowance as a part of the salary. While allowance is a fixed amount, medical reimbursement is a feature under which the employee’s medical expenses are reimbursed by the employer.

4. Mediclaim policy premium is not considered as medical expenditure. It is not taken into consideration for income tax exemption, but it can be considered for tax deduction on a separate basis under Section 80D of the Income Tax Act. 

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In case of any doubt or query, feel free to call InsuranceDekho. Our experts are ready to help you.