Respect Senior Care Rider: 9152007550 (Missed call)

Sales: 1800-209-0144| Service: 1800-209-5858 Service Chat: +91 75072 45858


Claim Assistance
Get In Touch
Role of TPA in Health Insurance
Oct 3, 2022

Five Things You Should Know About Reimbursement Claims Under Medical Insurance

Health issues can often be traumatizing, not just medically but also financially in some cases. During such an event, the financial safety net in the form of a health insurance policy comes to the rescue. Using a health insurance policy, the policyholder and the dependents need not worry about the steep treatment costs when time is of the essence in a medical emergency. For that, insurance companies make their claim process a hassle-free and quick, and straightforward process. But to avail a seamless claim experience, you, the policyholder, must be honest and transparent about your medical history and have patience when raising a claim. A health insurance claim is divided into two types based on how the insurance company pays — a reimbursement claim and a cashless claim. While the insurance company pays for the medical expenses incurred by the policyholder under a reimbursement claim, the insurer pays directly to the hospital in case of a cashless claim. Here are five things to know about reimbursement claims in your health insurance policy:

1. Knowing How the Reimbursement Claim Works

A reimbursement claim, as discussed above, is a way of compensation where the insurance company pays for the treatment costs after they have been paid by the policyholder. Depending on the health insurance coverage, the insurer compensates the policyholder for the costs of the treatment. So, as a policyholder, you need to pay the medical bills first, which will then be reimbursed by the insurance company. *

2. The Policyholder Must Initiate the Claim

It is your responsibility as a policyholder to initiate the insurance claim process, unlike cashless plans where the insurance company directly pays the medical facility. If the policyholder fails to lodge a claim for the treatment costs, the insurance company will not compensate the policyholder for the medical expenses. *

3. Furnishing Necessary Documents

A reimbursement policy requires the policyholder to provide the necessary documents to support the claim. This includes documents like medical bills, test reports, doctor’s prescriptions, and more. These documents form the basis on which the insurance company reimburses the treatment cost. In some cases, the insurance company may appoint a third-party administrator (TPA) to manage all claims and their documentation. This is not the same for all insurance companies. When submitting the documents, ensure to make photocopies as you are required to submit the original documents for perusal by the insurer or the TPA. *

4. Detailed Scrutiny

Each claim application is scrutinized thoroughly by the insurance company or the TPA. This intense scrutiny is done to ensure any fraudulent claims can be avoided, as these documents form the basis of a claim, unlike a cashless claim where it can be verified directly with the network hospital. *

5. Elaborate Process

In comparison to a cashless claim where the payout is directly made to the hospital within a few hours, reimbursement insurance claims require a few days. The process of verification of the claim is the longest and only begins after the submission of all the necessary documents by the policyholder. * *Standard T&C Apply  There are several policies to choose from, you need to pick a plan, be it a cashless or reimbursement policy, based on your requirements. In addition to it, you can make use of a health insurance premium calculator that helps users know about the premium for a policy based on the features opted for.   Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms and conditions, please read the sales brochure/policy wording carefully before concluding a sale.

Was this article helpful? Rate it

Average rating 5 / 5. Vote count: 18

No votes so far! Be the first to rate this post.

Like this article? Share it with your friends!

Share Your Thoughts. Leave a Comment Below!

Leave a Reply

Your email address will not be published. All fields are required