How to file a health insurance reimbursement claim after paying the hospital yourself

Tell the insurer or TPA about the claim as early as you can, collect the full set of hospital papers before you leave, and submit the claim form with those papers within the period your policy states. Once the claim is submitted, IRDAI requires a non-cashless health claim to be settled within 15 days, with interest at bank rate plus 2% if it is late. Keep copies of everything and proof of every submission.

A reimbursement claim is the route when you paid the hospital yourself: at a non-network hospital, after cashless was refused, or for bills before and after the admission. A reimbursement claim can run into problems of process as well as of cover, so a careful file now can save a dispute later.

Before you start: three things to find in your policy

• The notice deadline: When you must tell the insurer or TPA. One insurer's product asks for notice within 24 hours of an emergency admission or before discharge, whichever is earlier.^[1]
• The submission deadline: When the papers must reach the insurer. The same product asks for them within 30 days of discharge.^[1]
• The document list: Your policy document must list the documents needed for a claim and the procedure to follow, and say what happens if the timelines are not met.^{[2, 3]}

Step by step

1. 1

   Intimate the claim

   Tell the insurer or TPA at the earliest possible time, online, by phone, through the TPA or through the hospital where that facility exists. Note the reference number.^[3]

2. 2

   Collect the papers before discharge

   One insurer's product lists the claim form, photo ID, the doctor's prescription advising admission, original itemised bills, payment receipts and the discharge summary, plus test reports with the prescriptions that ordered them. Insurers and TPAs are also to collect documents from the hospital after intimation, but keep your own copies.^{[1, 4]}

3. 3

   Fill in the claim form

   Give bank details for payment, and disclose any other health insurance you hold; one insurer's wording requires it.^[1]

4. 4

   Submit within the deadline, with proof

   Send the papers within your policy's period and keep proof: a courier receipt, the email, or a stamped acknowledgement. Send originals only where the insurer asks for them, and scan every page first.^[1]

5. 5

   Claim pre- and post-hospitalisation bills

   Bills from before admission go with the main claim; bills after discharge have their own window, for example within 15 days of finishing that treatment. See pre- and post-hospitalisation expenses.^[1]

6. 6

   Answer queries once, completely

   Insurers must ask for all the documents they need in one go, not piece by piece. If a query arrives, reply in full and keep a copy; if an investigator calls, see what to expect from a claim investigation.^[2]

7. 7

   Watch the 15 days

   A non-cashless claim must be settled within 15 days of submission. If it is late, interest at bank rate plus 2% runs from the date of intimation and is to be paid without your asking. Bank rate means the RBI rate on the first day of the financial year in which the claim fell due.^{[3, 2]}

Mistakes that slow a claim down

• Bills in the wrong name: One insurer's wording accepts bills and treatment documents only in the name of the person being claimed for.^[1]
• Originals sent to another insurer: If the originals went to another insurer under a second policy, one insurer's wording accepts copies certified by that insurer with its settlement advice.^[1]
• Test reports without prescriptions: Send each investigation report with the prescription that ordered it.^[1]
• No proof of sending: Without a dated proof of submission, a deadline dispute becomes your word against the insurer's.

ClaimAssure is an independent private platform. It is not an insurer, IRDAI, Bima Bharosa or the Insurance Ombudsman, it never files anything on your behalf, and it cannot promise any outcome. What it does is read your documents and show you what they say.

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