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Imagine this: you’ve faced a sudden medical emergency, paid hefty bills upfront, and now need to recover your expenses.
This is where a reimbursement claim steps in, acting as your financial safety net. Submitting bills, prescriptions, and medical reports seamlessly transforms your out-of-pocket expenses into reimbursed relief.
It's not just a claim; it's a promise that your health comes first—even in unexpected moments. 😁
A reimbursement claim is an official request for compensation or a refund for out-of-pocket medical expenses made by a policyholder to their health insurance policy provider.
In simple words, a Reimbursement Claim is a type of claim in which an insured must pay for medical costs and treatment out of their own pocket and later claim the bill from the insurance provider. For this kind of claim, the insured can visit any hospital for treatment, not necessarily the empanelled cashless hospital.
Let’s understand this with an example:
Shweta has a health insurance policy and resides in Delhi. She had to undergo a minor nerve surgery, for which she visited her family neurospecialists. Unfortunately, the hospital she chose was not empanelled with the insurance company. 😣
After treatment, she paid the treatment cost herself and kept all the essential documents, invoices and receipts. She filled out a reimbursement claim for the insurance company and after verification, her expenses were returned to her. 🙂
The reimbursement claim process is simple: You go for treatment, you pay, we verify, and we pay you. However, the work is more complex than this! Let’s understand how a health insurance reimbursement claim works:
Seek Treatment and Pay Bills: Receive medical treatment at any hospital you choose and pay all medical expenses, including consultation fees, room charges, medications, and procedures, out of pocket.
Inform Your Insurance Provider: Notify your insurer about the hospitalization usually within 24-48 hours for emergency treatments and 3-4 days before planned treatments.
Collect and Organize the Required Documents: Collect all necessary documents like hospital bills, discharge summaries, prescriptions, diagnostic reports, and a completed claim form.
Submit the Claim: Compile all documents and submit them to the insurance company or the third-party administrator (TPA) within the timeline specified in your policy.
Approval and Reimbursement: Once approved, the insurer reimburses the claim amount directly into your registered bank account.
A reimbursement claim becomes necessary when you’ve paid for medical expenses out of pocket and must recover the costs from your insurer. This often happens when treatment is done at a non-network hospital in India where cashless facilities are unavailable.
Additionally, expenses such as pre and post-hospitalization costs, diagnostic tests, and outpatient treatments that aren’t covered under cashless claims may require reimbursement filing.
Let’s take different cases and understand which claim you should file in which situation:
Scenarios |
Type of Expense |
Type of Claim to File |
You went for planned surgery in a network hospital where the insurer settles the bill directly with the hospital. |
Hospitalisation |
Cashless Claim |
You had to undergo emergency surgery at a non-network hospital, where you had to pay the bills. |
Hospitalisation |
Reimbursement Claim |
You needed an immediate hospitalisation due to an accident. |
Accidental Hospitalisation |
Cashless Claim (network hospital) and Reimbursement Claim (non-network hospital) |
You underwent surgery in a network hospital in India, but your cashless claim was rejected due to missing documents. |
Hospitalization |
Reimbursement Claim |
You had to undergo a consultation and lab tests weeks before and after getting hospitalised for a medical procedure. |
Pre & Post Hospitalization |
Reimbursement Claim |
You had to visit a clinic weekly for skin allergy treatment without requiring hospitalisation. |
OPD Expenses |
Reimbursement Claim |
You can visit your desired healthcare facilities and utilise your health insurance benefits. It can be any other hospital rather than an empanelled cashless hospital to help you avail yourself of your health insurance benefits.
Before starting the treatment, you need not wait for the insurance provider's approval or other insurance-related procedures. You can receive immediate treatment at your desired hospital with a high state-of-the-art facility.
You can apply for a reimbursement claim as soon as your medical care is finished and the bills have been paid. This procedure removes delays and ensures a seamless and effective compensation experience.
When it comes to health insurance, Digit stands out with a remarkable 99% Claims Settlement Ratio (CSR). But this isn’t just a number, it’s a reflection of our core promise: to be there when it truly matters.
Every claim represents a moment of vulnerability for someone. A sudden illness. A hospital emergency. A family under pressure. At Digit, we understand that, and that’s why we work relentlessly to ensure that genuine claims are processed quickly, transparently, and with empathy.
Medical reimbursement claims might be a good option, considering their flexibility in selecting the medical centre for treatment. We can choose any desirable hospital, not just the empanelled hospital.
However, while opting for a reimbursement claim or selecting a non-network hospital, one must consider a few points as listed below:
It is of utmost priority to note your health insurance tenure and expiry date to ensure that you are not left without coverage when you need it the most.
You must carefully review your health insurance policy document and note all the exclusions and inclusions. When you have clarity on the extent of coverage from your health insurance, you can better plan your treatment and the claim process.
Not all health insurance plans cover the entire list of pre-existing diseases and medical conditions. Even if some insurance companies provide coverage for these, there might be a certain waiting period in health insurance before the coverage becomes active. Knowing the specified waiting period for diseases and exclusions makes you better prepared for your treatment.
In a reimbursement claim, you must check your funds' availability while planning for the treatment since the initial payment is made from pocket.
Keep a track of all the original documents- the bills, prescriptions, receipts, and all other documents necessary to file a claim.
One advantage of health insurance is the tax deduction. Learn how your taxes may be affected by your reimbursement. Recognize that some reimbursements might be subject to taxes while others might not. Therefore, it's critical to take tax implications into account while making financial decisions.
If you wish to opt for a hospital of your choice that might not be empanelled with your insurance provider, you can use the Reimbursement Claim. You can avail yourself of the medical treatment first, settle the bills, and then apply for a reimbursement claim from your insurance provider. Let’s take Digit’s health insurance policy as an example. If you choose a non-network hospital for treatment, here are the steps you must follow to submit a reimbursement claim:
Download the Digit Insurance App or file a health insurance claim option on the website.
Login and click on the "Health Claim Filing" option on the home page.
Select the type of claim you want to file from your active policies.
Fill out the Policy Details such as name, relationship with the policyholder, mobile number, etc.
Give a few details about the illness, such as the starting date of the symptoms, the first consultation date, the consultation hospital, etc.
Upload Documents such as the bill, discharge summary, test reports, valid ID proof, etc.
Although the exhaustive list might differ across insurance providers, here is a list of the most common documents required for a Reimbursement Claim:
At Digit, in the second half of FY25, the average turnaround time (TAT) for pre-authorisation of health insurance cashless claims was a speedy 26.93 minutes. Even better? Over 75% of requests were approved within 30 minutes, making the process feel almost instantaneous.
Of course, some requests, around 3.3% took a little longer (over 60 minutes), mainly because they needed extra info or clarification from hospitals or customers.
At Digit, in the second half of FY 2024-25, the average turnaround time (TAT) for hospital discharge approval in our health insurance was 58.95 minutes. Notably, 65% of discharge requests were completed within 60 minutes, ensuring patients aren’t left waiting once their treatment is finished.
While only 1.3% of cases extended beyond three hours, typically due to complex queries or pending clarifications.
Not every hospital is part of a cashless network, and that’s where reimbursement claims come into play. Once all documents are submitted, the average turnaround time for processing a reimbursement claim at Digit in FY 2024-25 was just 2.43 days.
Nearly 70% of claims were settled within two days, providing quick relief to policyholders who initially had to pay out of pocket. While about 4.5% of claims took over a week to settle, usually due to missing documents or follow-up queries, the process is largely smooth and customer-centric.
At the heart of smooth insurance experiences lies something you never see!! 😁
At Digit, our Health Claims Bots and Bulk Policy Issuance are quietly reshaping the way claims get processed. These smart systems fetch real-time data directly from the partner, eliminating manual uploads, reducing errors, and speeding up approvals for claims. In FY 2025 alone, they registered over 1.1 lakh claims, cutting down processing time.
No breaks and no delays. Fewer forms and faster care! ☺️
There are some reasons why claims can be rejected. It can either be because of documentation or false information. Let’s discuss the common reasons why your claim can be rejected:
Don't freak out if your reimbursement claim is denied. You can re-apply for a claim if the claim is rejected because of documentation. Here are some ways of how you can deal with claim rejections with the following actions:
You might have understood by now that reimbursement claims in health insurance offer a reliable solution for managing medical expenses when cashless facilities aren’t an option.
Understanding the process and ensuring all required documentation is in place can help you easily reclaim your financial outlays. This is crucial to ensuring comprehensive health coverage, giving you peace of mind and allowing you to focus on what truly matters—your recovery and well-being.
To monitor your reimbursement claim, you can: Check it on the app (if available) Ask directly to your TPA or insurer Get in touch with customer support
To monitor your reimbursement claim, you can:
The insurance company might take 2-4 weeks to process your reimbursement claim. However, this timeline varies from insurer to insurer. It is important that you read the policy document and stay in touch with your insurer for the claim.
The insurance company might take 2-4 weeks to process your reimbursement claim. However, this timeline varies from insurer to insurer. It is important that you read the policy document and stay in touch with your insurer for the claim.
No, the health insurance reimbursement claim is not taxable since it is not an income or a profit for the insured.
No, the health insurance reimbursement claim is not taxable since it is not an income or a profit for the insured.
Yes, there are certain advantages of having a cashless claim over a reimbursement claim because: A cashless claim is more convenient and effective. During a medical emergency, when the patient and family members are already under stress, a cashless claim takes the toll off their heads by paying the expenses. The policyholder does not have to pay any expense out of pocket. Some companies even provide hospital discounts if you get treated at their empanelled hospital.
Yes, there are certain advantages of having a cashless claim over a reimbursement claim because:
You or your family can notify your TPA about your hospitalization within two days of being admitted. This will help you initiate the reimbursement claim in the initial stage only.
You or your family can notify your TPA about your hospitalization within two days of being admitted. This will help you initiate the reimbursement claim in the initial stage only.
Yes, almost all kinds of hospitals offer reimbursement treatments. You can choose any hospital for your treatment and later apply for reimbursement for the same.
Yes, almost all kinds of hospitals offer reimbursement treatments. You can choose any hospital for your treatment and later apply for reimbursement for the same.
Yes, you should always review the policy's list of exclusions before obtaining reimbursement for health insurance. Every disease, ailment, and condition that is not covered by your insurance policy is listed here. As a result, your claim may be denied if you submit for an illness or condition covered by the exclusions.
Yes, you should always review the policy's list of exclusions before obtaining reimbursement for health insurance. Every disease, ailment, and condition that is not covered by your insurance policy is listed here. As a result, your claim may be denied if you submit for an illness or condition covered by the exclusions.
Usually, hospital bills, discharge summaries, prescriptions, diagnostic results, and the completed reimbursement claim form are among the paperwork you need to submit to your insurer for reimbursement.
Usually, hospital bills, discharge summaries, prescriptions, diagnostic results, and the completed reimbursement claim form are among the paperwork you need to submit to your insurer for reimbursement.
The majority of insurance covers room rent, surgery, medicine, diagnostic testing, and pre and post-hospitalization costs. However, always consult your policy to verify what can be reimbursed.
The majority of insurance covers room rent, surgery, medicine, diagnostic testing, and pre and post-hospitalization costs. However, always consult your policy to verify what can be reimbursed.
Yes, depending on your health insurance policy, waiting periods for particular treatments may apply to reimbursement claims just like they do to other claims. You must check your policy's waiting period before applying for a claim.
Yes, depending on your health insurance policy, waiting periods for particular treatments may apply to reimbursement claims just like they do to other claims. You must check your policy's waiting period before applying for a claim.
No, you cannot file a reimbursement claim for the costs your policyholder does not cover. It is made for costs that your insurer covers. Reimbursement may not be available for expenses that are specifically excluded from your policy.
No, you cannot file a reimbursement claim for the costs your policyholder does not cover. It is made for costs that your insurer covers. Reimbursement may not be available for expenses that are specifically excluded from your policy.
Yes, certain insurance providers might offer faster processing in an emergency. Contact your insurance company for advice on how to handle emergencies.
Yes, certain insurance providers might offer faster processing in an emergency. Contact your insurance company for advice on how to handle emergencies.
Yes, if you die during hospitalisation, your nominee can get both payouts: hospital bills reimbursed through your health insurance, and a lump sum death benefit from your life insurance or term insurance policy, provided both are active and all conditions and disclosures are properly met.
Yes, if you die during hospitalisation, your nominee can get both payouts: hospital bills reimbursed through your health insurance, and a lump sum death benefit from your life insurance or term insurance policy, provided both are active and all conditions and disclosures are properly met.
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For policies with a risk commencement date on or after October 1, 2024, all servicing activities, including without limitation claims processing and grievance redressal, shall be in compliance with the provisions of the IRDAI (Insurance Products) Regulations, 2024 dated March 20, 2024 and IRDAI (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024 dated March 22, 2024 read with relevant Master Circulars.
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Author: Team Digit
Last updated: 31-07-2025
CIN: L66010PN2016PLC167410, IRDAI Reg. No. 158.
Go Digit General Insurance Limited | Corporate Office Address: Atlantis, 95, 4th B Cross Road, Koramangala Industrial Layout, 5th Block, Bengaluru 560095 | Registered Office Address: 1 to 6 floors, Ananta One (AR One), Pride Hotel Lane, Narveer Tanaji Wadi, Shivaji Nagar, Pune-411005, Maharashtra | Trade logo of Go Digit General Insurance Ltd. displayed above belongs to Go Digit lnfoworks Services Private Limited and is provided and used by Go Digit General Insurance Ltd. under license.
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