Reimbursement Health Insurance: What You Need To Know

A health insurance claim can be of two types - reimbursement claim and cashless claim. As a health insurance policyholder, you should be aware of both types of claims so that you know what course of action to take in times of emergency. In a reimbursement claim, the policyholder makes the payment and then raises the claim. If the claim is approved, the insurer makes the required reimbursement accordingly. In a cashless claim, the claim is made during the hospitalisation and the payment is made directly by the insurer to the network hospital.* Claims are subject to terms and conditions set forth under health insurance policy. Reimbursement health insurance is the more conventional out of the two. In this article, we take a deep dive into reimbursement health insurance and explore its various aspects.

How does Reimbursement Health Insurance Work?*

To understand how reimbursement health insurance works and differs from its counterpart, let us see how it works.

1. Once you buy the reimbursement health insurance plan, you are covered under it as per its terms and conditions.
2. In the case of a medical emergency, you can seek medical treatment at any hospital of your choice.
3. The treatment expenses would have to be borne by you for the moment. You must keep all the bills, receipts and records safely with you.
4. Once you are able to, you must submit a claim to the insurance company for the medical expenses (if they are covered within the health insurance plan) within the stipulated time.
5. For the claim, you must fill out the relevant form and submit the necessary documents (bills and other medical records) to the insurance company.
6. Once submitted, the claim documents will be verified by the insurer. In case of any additional assistance, they may reach out to you.
7. If the claim is approved, you will receive the payment (i.e., the reimbursement) for the medical expenses, in accordance with the policy’s terms and conditions.

Apart from reimbursement and cashless claims, some general insurance plans, such as critical illness insurance, have a benefit-based claim process. Here, the insurer makes a pre-defined pay-out (after which the policy may cease to operate) if the insured person is diagnosed with a particular illness or has to undergo surgery. These are called defined-benefit health insurance plans.*

Features and Benefits of Reimbursement Health Insurance 

Now that you know how reimbursement health insurance works, let’s understand how it may benefit policyholders.

You can choose any hospital you want*

Unlike cashless health insurance where you are bound to a pre-approved list of hospitals, you can choose any hospital for treatment with reimbursement health insurance. This way, you choose a hospital where you believe you may get the right treatment.

Claim can be raised post-treatment*

One of the benefits of reimbursement health insurance is that one can apply for a claim after their medical treatment is complete and the bills are settled. This ensures that you do not have to worry about any administrative problems during your treatment. Instead, you can focus on rest and recovery.

Personalised healthcare choices*

Your health is personal, and so should your healthcare choices. Reimbursement health insurance allows you to make your medical decisions based on your preferences and requirements. This ensures that your health insurance aligns with your unique needs, which can encourage a stronger sense of control over your well-being. Claims are subject to terms and conditions set forth under health insurance policy.

Things to Know Before Opting for Reimbursement Health Insurance Claim

Every general insurance claim is carried out via a specific procedure. When it comes to reimbursement health insurance, these are some things you should know:

Know what is covered*

You must thoroughly review your policy to make sure that the expenses you are opting for are covered under the plan. Raising a claim for a medical issue which may be excluded may lead to a waste of time and energy.

Maintain all medical records

Remember to keep all receipts and documents related to the medical treatment for future reference safely.

Know claim time limits

When it comes to raising a claim, every insurer has a time limit. Hence, be mindful of claim time limits to ensure that you submit everything on time.

Be aware of the sub-limits*

A sub-limit refers to a limitation on a particular expense related to medical treatment. For instance, some health insurance plans have a room rent sub-limit; medical expenses under ‘room rent’ shall be reimbursed only till a particular amount or a percentage of the total amount.

Know that cashless options are available*

All health insurance plans are likely to have a cashless feature. So, if you are unable to pay large amounts of cash upfront for treatment, you can consider cashless health insurance as well. Claims are subject to terms and conditions set forth under health insurance policy. Before you opt for reimbursement health insurance, you should get an idea of its premium. For that purpose, you can use a health insurance calculator.   *Standard T&C apply. Disclaimer: The content on this page is generic and shared only for informational and explanatory purposes. It is based on several secondary sources on the internet and is subject to changes. Please consult an expert before making any related decisions. 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.