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Reimbursement Claim in Health Insurance
A reimbursement claim in health insurance is when you pay for your medical treatment out of pocket and later submit a claim to your insurer to get that money back.
This type of claim is typically used when you receive treatment at a non-network hospital or in situations where cashless services aren’t available. While it requires you to handle the hospital bills initially, the insurer reimburses you for eligible expenses once you submit the necessary documents and the claim is approved.
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Meaning of Reimbursement Claim in Health Insurance
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 neurosurgeon. 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. 🙂
Benefits of a Reimbursement Claim in Health Insurance
No Location Constraints
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.
Immediate Treatment
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.
Flexibility in Claim Process
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.
How Does the Reimbursement Claim Process Work?
A reimbursement claim works by allowing you to pay for your medical treatment upfront and then recover the eligible expenses from your health insurance provider. Here's a step-by-step explanation of how it works:
Get Treated at Any Hospital
Select any hospital (whether within a network or not) for treatment.
Pay & Keep the Bills
Settle all medical expenses upfront from your own pocket and keep the bills or invoices, such as those for doctor’s consultations, diagnostic reports, and hospital bills.
Submit a Claim to the Insurer
Complete the claim form and submit it along with the required supporting documents.
Claim Review & Verification
The insurer reviews your documents to verify the treatment, expenses, and policy coverage. They may request additional documents if necessary.
Approval and Reimbursement
Once approved, the insurer reimburses the claim amount directly into your registered bank account.
How to File a Reimbursement Claim at Digit?
Get Treated & Save Everything
Visit any hospital, pay the bills upfront, and collect all the necessary documents (bills, reports, prescriptions, discharge summary, etc).
Open Digit App & File Claim
Log in to the Digit App. Navigate to the ‘File a Health Claim’ section on the app. Choose the policy, enter your details and & type of claim (reimbursement claim).
Enter Details & Upload Documents
Fill out additional details of treatment, symptoms, hospital details, etc. Scan and submit all the necessary documents in the desired format.
Register Claim & Relax
Click ‘Register Claim.’ We’ll review everything, and once approved, the amount will be reimbursed directly to your bank account.
Documents Required for Reimbursement Claims
When filing a health insurance claim, you need to submit certain documents to ensure a smooth and hassle-free process. Below is a list of essential documents that may be required while filing a reimbursement health claim at Digit:
Hospitalisation Documents
×
✔ Original hospital bills & payment receipts
✔ Detailed discharge summary
✔ All diagnosis reports (lab tests, imaging, etc.)
✔ Doctor’s consultation & prescription copies
✔ Pharmacy and medicine bills
Cashless Documents
×
✔ Duly filled & signed claim form (Available at the hospital or on Digit’s website/app)
✔ Diagnosis report for confirming the need for hospitalisation
✔ Health E-card
KYC Documents
×
✔ Aadhaar Card (Identity & address proof)
✔ PAN Card (Financial verification)
✔ Photograph
✔ Bank Details (Passbook or cancelled cheque)
When Should You File a Reimbursement Claim?
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-hospitalisation 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 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-Hospitalisation Claim |
|
You had to visit a clinic weekly for skin allergy treatment without requiring hospitalisation. |
OPD Expenses |
Reimbursement Claim |
Factors to Consider Before Filing a Reimbursement Claim
Medical reimbursement claims might be a good option, considering the flexibility they provide in terms of 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:
Reasonable and Customary Charges under Reimbursement Claims
For both network and non-network hospitals, reasonable and customary charges, which are the standard charges for a specific provider and consistent with prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness /injury involved, and which are medically necessary, will be considered for payment of admissible claims.
In case treatment is received at a Network hospital, payment of claims will be as per Digit’s pre-negotiated rates with the hospital and in case treatment is received at a non-network hospital, reimbursement will be limited to rates applicable at par with another comparable network hospital.
Common Reasons for Reimbursement Claim Rejection
This may sound unusual, but there are several reasons why claims can be rejected. It can be due to either documentation or incorrect information. Let’s discuss the common reasons why your claim can be rejected:
- Insufficient Documentation: Bills, invoices, and medical records are missing or incomplete, which may result in a claim being denied.
- Exclusions from the Policy: Certain treatments may not be covered, depending on the terms and conditions of your policy.
- Waiting Period Not Over: Especially in health insurance, some conditions have a waiting period before claims can be made. According to Digit’s Transparency Report, around 8% of health claims were rejected mainly due to waiting periods.
- False Information: Your claim form may only be accepted if you provide correct or sufficient information.
- Non-payment for the Policy: Any claims made during this time may be denied if your coverage has lapsed due to non-payment of premiums.
What to Do if Your Reimbursement Claim is 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 you can deal with claim rejections with the following actions:
- Examine the Notice of Rejection: Please examine the notice of rejection that your insurance company sent you carefully and recognise the precise justifications for the rejection.
- Speak with Your Insurance Company: Ask your insurance company for more information. Request clarification on the reasons for the rejection and advice on the next course of action.
- Review the Policy Coverage Twice: Verify that your policy paperwork accurately reflects the costs you reported. Misunderstandings or misinterpretations can occasionally lead to rejections.
- Fix Any Mistakes: Correct any mistakes in the original claim filing as soon as possible.
- Obtain Medical Advice or Records: If the rejection was caused by a disagreement regarding the necessity of the therapy, consider getting a second medical opinion or acquiring more supporting paperwork from your healthcare provider.
- Follow up Continuously: Throughout the appeals process, communicate continuously with your insurance carrier and record every conversation.
Digit’s Health Insurance Claim Numbers for FY 2024-25
75% of Cashless Health Claims Approved in Just 30 Minutes at Digit
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.
65% Cashless Discharge Approved in Just 60 Minutes at Digit
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.
Almost 70% of Reimbursement Claims Settled in Just 2 Days
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.
1.1 Lakh+ Claims Registered Quickly with Smart Health Claim Bots in FY 2024-25
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! ☺️
Interesting Claim Stories about Digit Health Insurance
Highest Health Claim of ₹16.77 Lakh Settled by Digit in FY 2024-25
A Bengaluru customer faced a serious and complex medical condition, leading to a treatment bill running into lakhs. Digit settled its highest health insurance claim in FY 2024-25, amounting to approximately ₹16.77 lakh.
What mattered more was how quickly and transparently we stepped in. From the initial notification to the final settlement, the entire claim was handled with empathy, clarity, and minimal stress.
At Digit, it’s not the size of the bill that moves us; it’s the trust behind every claim we settle. 🙂
Over ₹27 Crore Settled for Pre and Post-Hospitalisation Expenses in FY 2024-25
At Digit, we believe health insurance is more than just hospital bills. This year, a patient undergoing treatment for malignancy received coverage not only for their hospitalisation but also for over 10 pre and post-hospitalisation visits, with a total payout exceeding ₹1.4 lakh. This reflects our commitment to supporting patients through every step of their recovery journey.
In fact, Digit paid out more than ₹27 crore this year alone towards pre and post-hospitalisation expenses, proving that genuine care extends before and after hospitalisation as well.
This is what we mean when we say insurance that supports the full journey, not just the hospital stay. 🙂
7,747 Babies Covered Under Their Parents' Policies in FY 2024-25
In FY 2024-25, Digit proudly covered around 7,747 babies under their parents’ policies, protecting the newest generation with the same care and commitment as every policyholder.
Among these little ones, the most popular baby names were Shivansh and Fatima, reflecting the diverse families Digit supports across India. 🙂
This wouldn’t be possible without Digit’s flexible family health plans, which automatically extend coverage to newborns, making it easy for parents to safeguard their little ones from day one.
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.
FAQs about Reimbursement Claims in Health Insurance
How Can I Monitor the Progress of My Reimbursement Claim?
To monitor your reimbursement claim, you can:
- Check it on the app (if available)
- Ask your TPA or insurer directly
- Get in touch with customer support
How long does it take for the reimbursement claim to be processed?
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. At Digit, in FY 2024 - 25, almost 70% of reimbursement claims were settled in just 2 days.
Is a health insurance reimbursement claim taxable?
No, the health insurance reimbursement claim is not taxable since it is not an income or a profit for the insured.
What is the advantage of a Cashless claim over a Reimbursement claim?
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 expenses out of pocket.
- Some companies even provide hospital discounts if you receive treatment at their empanelled hospitals.
When can I let my TPA know that I'm in the hospital?
You or your family can notify your TPA about your hospitalisation within two days of being admitted. This will help you initiate the reimbursement claim in the initial stage only.
Are there any hospitals that offer reimbursement for treatments?
Yes, almost all kinds of hospitals offer reimbursement for treatments. You can choose any hospital for your treatment and later apply for reimbursement for the same.
Are there any exclusions from reimbursement for health insurance?
Yes, you should always review the policy's list of exclusions before obtaining reimbursement for health insurance. Every disease, injury, 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.
What paperwork is needed to submit a claim 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.
What costs are eligible for reimbursement?
The majority of insurance covers room rent, surgery, medicine, diagnostic testing, and pre and post-hospitalisation costs. However, always consult your policy to verify what can be reimbursed.
Does the reimbursement claim process have a waiting period?
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.
Can I file a claim for reimbursement for costs that my policy does not cover?
No, you cannot file a reimbursement claim for the costs your policy does not cover. It is designed to cover costs that your insurer pays. Reimbursement may not be available for expenses that are specifically excluded from your policy.
Can we speed up the reimbursement process in an emergency?
Yes, certain insurance providers might offer faster processing in an emergency. Contact your insurance company for advice on how to handle emergencies.
If I die during hospitalisation, will my nominee get both insurance payouts and hospital bill reimbursements?
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.
What documents are required to file a reimbursement claim?
Typically, you will need the hospital bill, discharge summary, prescriptions, diagnostic reports, payment receipts, and a completed claim form. Some insurers may ask for additional documents for the KYC process.
Is there a time limit to submit a reimbursement claim after treatment?
Yes, most insurers require you to submit the claim within 30 to 90 days from the date of discharge. Check your policy for exact timelines.
Can I file a reimbursement claim for pre- and post-hospitalisation expenses?
Yes, if your policy includes this coverage, you can claim expenses incurred before and after hospitalisation, usually within a specified time frame.
Can I submit a reimbursement claim online at Digit?
Yes, Digit allows you to submit reimbursement claims through their website or mobile app by uploading scanned copies of the required documents.
What happens if I lose my original hospital bills?
Original bills are usually required for reimbursement. If you lose your documents, you should request duplicates from the hospital and provide a written explanation to the insurer.
Is there a limit on the amount I can claim through reimbursement?
Yes, the claim amount is subject to your policy’s sum insured and sub-limits for specific treatments or services.
Can I claim reimbursement for treatment taken outside India?
Yes, you can claim reimbursement for treatment taken outside India only if your policy includes international coverage. Most standard policies cover treatment within India only.
What are the top reasons Digit may reject a reimbursement claim?
Common reasons include incomplete documents, treatment not covered under the policy, or filing beyond the allowed timeline. In FY 2024-25, around 8% of health claims were rejected mainly due to waiting periods.
Does Digit cover home treatment (domiciliary care) under reimbursement claims?
Yes, if domiciliary hospitalisation is covered under your plan or your parents' plan and meets the conditions, you can file a reimbursement claim for it.
Do I need to submit physical copies of documents for a reimbursement claim?
No, Digit follows a paperless process. You only need to upload clear scanned copies or images of documents via the app or email.
How do I know if my treatment is eligible for a reimbursement claim with Digit?
You can refer to your policy document and confirm what is covered before filing a reimbursement claim.
Is there a separate reimbursement form I need to fill out for Digit claims?
Yes, Digit requires you to fill out a reimbursement claim form, which is available on their website or app. It must be submitted along with supporting documents.
Can I claim reimbursement for diagnostic tests done before hospitalisation?
Yes, pre-hospitalisation expenses, including diagnostic tests are reimbursable if done within the allowed window (typically 30 days before admission).
What happens if I forget to attach a required document in a reimbursement claim?
Digit will notify you via email or SMS and allow you to resubmit the missing document within a specific time frame
Can I split a single hospital bill and file multiple reimbursement claims?
No, you must submit the entire hospital bill as part of one consolidated reimbursement claim per treatment or hospitalisation event.
What are reasonable and customary charges under health reimbursement claims?
Reasonable and customary charges are the usual fees a provider charges, aligned with typical rates in the local area for the same or similar services. For both network and non-network hospitals, admissible claims are paid up to these amounts, considering the nature of the illness/injury and only for medically necessary care.