Reimbursement claim process in health insurance, documents and deadlines

When you need a reimbursement claim

You file a reimbursement claim when you pay the hospital yourself and then ask the insurer to pay you back. This happens when:

• The hospital is not in your insurer's network. IRDAI's Master Circular of 29 May 2024 makes insurers state on their websites that such stays need a reimbursement claim.
• Cashless was refused or not approved in time, and you paid to get treated or discharged.
• You are claiming pre-hospitalisation or post-hospitalisation costs covered by your policy.

Step by step

1. Intimate the claim early. The September 2024 policyholder master circular lets you tell the insurer online, through your agent or broker, through the TPA, at the hospital where that facility exists, or through the insurer's call centre.
2. Collect documents before you leave the hospital. Originals are hard to get later.
3. Submit within your policy's time limit. The limit is in your policy wording.
4. Answer any query quickly and keep a copy of every reply.
5. Read the settlement letter. If anything is cut, the reason must cite the specific policy term.

The documents

The standard policy wording IRDAI published in July 2020 lists these documents for a reimbursement claim. Your insurer may ask for fewer, or waive originals.

• The completed claim form.
• Photo identity proof of the patient.
• The doctor's prescription advising admission.
• Original bills with an itemised break-up, and payment receipts.
• The discharge summary with the patient's medical history.
• Test and scan reports, with the prescriptions that ordered them.
• Operation notes or the surgeon's certificate, for surgery.
• The sticker or invoice for any implant.
• The medico-legal report and FIR, where one exists.
• Bank details and a cancelled cheque for direct credit.
• Identity and address proof of the proposer, which this example wording asks for when the claim is above ₹1 lakh.
• A legal heir or succession certificate, where needed.

Bills must be in the name of the patient being claimed for. If you sent originals to another insurer, the 2020 wording let insurers accept copies certified by that insurer.

The deadlines

1. 30 daysYou, for the hospital stay
2. 15 daysYou, for post-hospital costs
3. 15 daysInsurer, to settle

Rules that protect you

The 2024 master circulars add several protections:

• No claim shall be rejected or closed for want of documents or for delayed intimation.
• After you intimate a claim, insurers and TPAs must collect the required documents from the hospital, and the policyholder "shall not be required to submit the documents". Keep your own copies anyway.
• The insurer's Product Management Committee, or its three-member Claims Review Committee, must approve every rejection.
• Any rejection or partial cut must come with full reasons and a reference to the specific policy terms.
• The interest for delay is paid by the insurer on its own, without a request.

What changed in 2024

Policy wordings written to the 2020 standard said the insurer had 30 days from the last necessary document to settle, or 45 days if it investigated. The September 2024 master circular sets fifteen days from submission for claims other than cashless. Some web pages still quote the 30-day rule. If your policy wording shows an older timeline, the 2024 master circular is the current IRDAI position.

Have a hospital stay coming up? Send your policy on WhatsApp and a person checks it for you.