Reimbursement Claim Process in Health Insurance: A Comprehensive Guide

Having a health insurance policy can be useful when a medical emergency strikes. You can raise a claim with your health insurance provider in such a situation. Once the claim is processed and settled, the insurance company can help in regard to the financial payment for the treatment of the medical emergency. * The process to raise a claim can differ between insurance companies. There are two types of claims as well - cashless claims and reimbursement claims. In a cashless claim, the insurer takes care of the payment directly with the network hospital. In a reimbursement claim, the policyholder can choose a hospital of their preference and pay for the treatment expenses. They will be reimbursed by the insurer later. * Claims are subject to terms and conditions set forth under health insurance policy. Let us take a detailed look at the reimbursement claim process of Bajaj Allianz General Insurance Company.

How to Raise a Reimbursement Health Insurance Claim

Keeping your care and comfort in mind, we, at Bajaj Allianz General Insurance Company, have created a simple, no-frills health insurance claim procedure. Here is the process, categorised into different steps for a clearer understanding:

1. Intimate the insurance company

We understand that in times of medical crisis, you may find it difficult to reach out to the insurance company right away. However, we request you reach out at the earliest you can. In case of planned hospitalisation, you can also inform us prior to the admission, so that there is a lesser strain on you during the hospitalisation process.

2. Pay bills and collect documents

As you have opted for a reimbursement claim, you must pay the bills from your pocket for now. Ensure to keep each bill and invoice safe with you. Along with the bills, you also need to collect other hospitalisation-related documents in the original. A list of documents needed to claim health insurance is available in a later section of the article.

3. Submit the claim form and documents 

Now, after the payment process has been completed from your end, you need to share the relevant documents with the insurance company. You also need to fill out the claim form with the right information. In case you need help in knowing How to fill Final Claim Form, you can view this resource to get the assistance you need.

4. Let the insurance company verify and enquire

Based on the information submitted by you, the insurance company will verify the claim. In case more information is needed or there is a deficiency of certain documents, they will reach out to you. Once all requirements have been satisfied, the insurance company will settle the claim within a specified number of days. At Bajaj Allianz General Insurance Company, you can bank on us to initiate the health claim settlement process and release the payment within 7-10 working days. Claims are subject to terms and conditions set forth under health insurance policy. Note: You can raise a health insurance claim digitally as well. The reimbursement claim form can be availed by visiting the website of the insurance company or by running a search.

Documents Needed for Reimbursement Health Insurance Claim

Along with the claim form, the documents required for Mediclaim reimbursement process are as follows:

1. Discharge summary of the patient (original)
2. Hospital bill, with a detailed break-up of the costs (original)
3. Paid receipts (original)
4. Lab and test reports
5. Copies of invoices/ stickers/ barcodes in case of implants
6. First consultation letter from a doctor
7. KYC form
8. NEFT form, filled and signed by the policyholder/ proposer

In case the insured person has passed away during hospitalisation, additional documents, such as the original death summary document and legal heir certificate might be required. Claims are subject to terms and conditions set forth under health insurance policy.

Can a Health Insurance Claim be Denied?

Yes, the insurance company can reject your claim due to several reasons. Broadly, the claim may be rejected if it does not fall into the insurance policy’s purview. Some specific reasons which may lead to health insurance claim rejection include:

1. Treatment for an illness/ medical event not covered by the health insurance plan.
2. Suppression or misrepresentation of a relevant medical fact by the policyholder.
3. Treatment and the subsequent claim found to be unnecessary and unsupported/ fraudulent.
4. Claim made during the waiting period for a pre-existing or specified disease as listed in the policy.

A claim can be denied for multiple other reasons. To get a complete list of the exclusions, you should read through the entire contents of your health insurance policy document. Knowing how to raise a claim and the documents required for it can be helpful in times of emergency. If you have health insurance for family coverage, make sure your loved ones are also aware of the claim process. This can help them be stress-free in times of medical emergency. For additional assistance, you can also reach out to us at 1800-209-5858 or email us at: bagichelp@bajajallianz.co.in.  Claims are subject to terms and conditions set forth under health insurance policy.   * Standard T&C apply 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.