What is a Reimbursement Claim?
A reimbursement claim is an alternative to the Cashless medical insurance claim, where the claimant pays for the medical expenses out of their pocket and later applies for the insurance.
When is an out-of-pocket claim applicable for you: Reimbursement claim vs Cashless claim?
1. Required Treatment unavailable in a Network Hospital – Cashless claims are granted only for treatments availed in network hospitals. So if the individual wishes to get their treatment of choice outside the network, they can use this option.
2. Emergency Medical Treatment – In situations of urgent need of medical care like hospitalization, or long-term treatments like diabetes, individuals often choose to pay themselves on the spot and later file the claim for their hospital expenses. This way, they don't have to wait for claim approval to get the much-needed treatment.
3. Cashless Claim Approval taking too much time – Due to various reasons, the cashless claim can take more time to get approved. It is usually due to unforeseen technical or administrative hurdles by the hospital or the insurance provider.
4. Partial Approval of medical expenses under Cashless claim – In many cases, the claimant is only able to get part of their medical expenses insured under the Cashless scheme. In those situations, they can get the rest of the expenses insured through reimbursement.
5. In-Network Hospital does not offer Cashless Service – Sometimes, network hospitals do not provide Cashless insurance services for the desired insurance provider or insurance policy. In which case, the only viable option becomes reimbursement.
How to apply for reimbursement of medical expenses with SimpliInsure?
Step 1: Inform your Insurance Provider
Your insurer or any Third Party Administrator (TPA) needs to be informed about planned hospitalizations and treatments in advance, or at the earliest possible time for unplanned emergencies.
Step 2: Pay your Hospital or Treatment Bills
The medical expenses need to be settled directly with the healthcare provider, and all the medical receipts and invoices are to be saved for claiming the insurance later.
Step 3: Collect all Medical Documents related to the Treatment
To help claim the reimbursement later, make sure that you preserve the following documents:
● Original bills and receipts,
● Discharge summary,
● Doctor’s prescriptions,
● Diagnostic reports,
● Consultation papers
● Pharmacy bills, and
● Implant stickers if applicable.
Step 4: Fill out the Reimbursement Claim Form
Provide complete details to prevent delays in claim approval:
● Policy number,
● Patient information,
● Hospitalization dates,
● Diagnosis and treatment details,
● ID Proofs, and
● Bank details for receiving the claim amount.
Step 5: Submit Claim Form & All Supporting Documents
Other than physical submissions, documents can also be submitted online to your Insurer or Third Party Administrator (TPA) through Insurance portals, mobile apps, or emails.
Take care to have original copies of all documents at hand.
Claim Approval Process
Your insurer will check the details of your claim to validate them:
● Policy coverage
● Waiting Periods
● Exclusions
● Medical Necessity of your treatment
● Submitted documents
Additional Documents may be requested based on special circumstances:
● FIR for accident-related claims
● Previous medical records
Step 7: Claim Approval
Once the claim has been reviewed and approved, the claim amount will be credited to the bank account provided. An insurance claimant may see discrepancies in the insured amount, due to possible:
● Policy exclusions
● Co-payment clauses
● Non-payment items
● Deductibles, and
● Room rent limits
Common mistakes leading to Claim rejection
Claims may be rejected due to many reasons, which may be either intentional or unintentional. Hence, care must be taken to thoroughly review policy terms along with the submitted policy forms and supporting documents to avoid any unfavorable outcomes.
1. Delay in Informing the Insurance Provider – Planned hospitalizations should always be informed about to the insurer promptly. Even in emergency situations, there is a fixed time limit before which the insurer must be notified to avoid undue delays or rejection in your claim.
2. Non-Renewal of Policy – Care should be taken to make consistent payments towards your policy so that all unforeseen treatments are taken care. Claims are always rejected if policy payments are lapsing.
3. Claiming Reimbursement during the Waiting Period of the Policy – Every policy has a waiting period, after which claims to it can be made. Care should be taken to note the period that is relevant to your treatment, so that you need reimbursements only after the waiting period is over.
4. Undisclosed Medical History – Insurance claims require one to disclose previous and ongoing ailments like diabetes, thyroid disorders, hypertension, and previous surgeries done, to prevent rejection of the claim.
5. Claims Made on Policy Exclusions – Medical insurance policies often do not include cosmetic surgeries and many other treatments, and the claimant must be familiar with their policy exclusions.
How to handle Rejection of your Insurance Claim
To ensure that you do not go through unnecessary hassles in claiming your reimbursement, make sure to do the following:
● Read your policy terms very carefully, including terms on Exclusions and Waiting Period.
● Promptly inform your insurance provider, along with disclosure of all major medical conditions and previous treatments availed.
● Keep a record of all treatment documents and expenses.
● Do not forget to renew your policy.
This is also why you should take time to choose your policy, and with professional help if necessary.
In Short
Insurance claims do not need to be difficult and confusing. By taking care of a few steps, you can get the help for your medical needs on time.
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