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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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What is Reimbursement Claim in Health Insurance?
A reimbursement claim is a type of health insurance claim where you first pay the hospital bills from your own pocket and then request your insurer to reimburse the eligible medical expenses as per your policy terms and conditions.
This claim method is commonly used when you receive treatment at a hospital that is not part of your insurer's network hospital list or when cashless treatment is not available for any reason.
For example, if your hospitalisation bill is ₹1 lakh and you pay the entire amount at discharge, you can file a reimbursement claim with your insurer. After verification, the insurer will reimburse the eligible expenses covered under your health insurance, subject to the sum insured, policy terms, exclusions, and any applicable deductibles or co-payments.
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:
Notify Your Insurer & Get Treated at Any Hospital
Notify your insurer about the hospitalisation and choose any hospital (whether within a network or not) for treatment.
Receive Treatment & 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.
When Should You File a Reimbursement Claim?
You should file a reimbursement claim when you are unable to use the cashless health insurance and have paid the medical expenses yourself. Here are some common situations where a reimbursement claim may be required:
What is the Difference Between Reimbursement Claim vs Cashless Claim?
Both cashless and reimbursement claims help you receive health insurance benefits for covered medical expenses. The key difference lies in who pays the hospital bill initially and how the claim is settled.
When is a Reimbursement Claim Better Than a Cashless Claim?
While cashless claims are often preferred for their convenience, there are situations where a reimbursement claim can be a better or more practical option. A reimbursement claim may be a better choice in the following situations:
How to File a Reimbursement Claim at Digit?
If you have received treatment at a non-network hospital or paid your medical expenses out of pocket, you can file a reimbursement claim with Digit by submitting the required claim documents for review.
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 & Track Status
Click ‘Register Claim.’ We’ll review everything, and once approved, the amount will be reimbursed directly to your bank account.
What are the Documents Required for Reimbursement Claims?
To process a reimbursement claim, you must submit the required documents to your insurer as proof of hospitalisation, treatment received, and expenses incurred. Below is a list of essential documents that may be required while filing a reimbursement health claim:
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)
What are the Benefits of a Reimbursement Claim in Health Insurance?
A reimbursement claim offers flexibility when you need medical treatment but cannot avail of a cashless claim facility. It allows you to pay for treatment first and later recover eligible expenses from your insurer as per your policy coverage.
Some key benefits of a reimbursement claim include:
Access to Any Hospital
You are not restricted to file a claim only at cashless network hospitals. You can receive treatment at any recognised hospital and later file a reimbursement claim with your insurer.
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.
Suitable for Planned and Emergency Hospitalisations
Reimbursement claims can be filed for both planned treatments and emergency medical situations, provided the expenses are covered under the policy.
Important Things to Know Before Filing a Reimbursement Claim
Following the correct process and maintaining the required documents can make reimbursement claim settlement smoother and help avoid delays or rejections. While opting for a reimbursement claim or selecting a non-network hospital, you should consider the following points:
Inform Your Insurer Within the Required Timeline
Notify your insurer or TPA about the hospitalisation as soon as possible. Delayed intimation may affect claim processing, especially if it exceeds the timelines specified in your policy.
Check Coverage Under Your Policy
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.
Waiting Period for Specific Diseases
Not all health insurance plans cover the entire list of pre-existing diseases and medical conditions. There might be a certain waiting period before the coverage becomes active. Knowing the specified waiting period in health insurance helps you better prepare for your treatment.
File the Claim Within the Submission Deadline
Most insurers require reimbursement claims to be submitted within a specified period after discharge. Missing the deadline could affect your claim eligibility.
Keep Your Documents Secure
Keep a track of all original documents such as bills, prescriptions, receipts, and all other documents necessary to file a claim.
Recognise the Tax Implications
One advantage of health insurance is the tax deduction. Learn how your taxes may be affected by your reimbursement. Recognise 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.
What are the Common Reasons for Reimbursement Claim Rejection?
While reimbursement claims can help recover eligible medical expenses, they may be delayed, partially approved, or rejected if policy requirements are not met. Understanding the common reasons for claim rejection can help you avoid mistakes and improve the chances of a smooth claim settlement.
- Delayed Claim Intimation or Submission: Most insurers require policyholders to inform them about the hospitalisation and submit claim documents within a specified timeline. Missing these deadlines may lead to claim rejection.
- 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. Hence, always check exclusions in health insurance before claim filing.
- 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 may only be accepted if you provide correct or sufficient information.
- Claim Amount Includes Non-Medical Expenses: Items such as administrative charges, registration fees, personal comfort items, food for attendants, or other non-payable expenses may not be covered under the policy.
- Non-payment for the Premium: Any claims made during this time may be denied if your coverage has lapsed due to non-payment of premiums.
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What to Do if Your Reimbursement Claim is Rejected?
In many cases, claims are rejected due to missing documents, insufficient information, policy exclusions, or procedural issues that may be clarified or corrected. However, you can re-apply for a claim if the claim is rejected because of documentation. Understanding the reason for rejection is the first step towards resolving the issue.
- Review 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.
- Submit Additional Documents, if Required: If the rejection occurred because of missing or incomplete documents, you may be able to provide the required records, bills, reports, prescriptions, or payment proofs and request a reassessment of the claim.
- 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: Verify that your policy paperwork accurately reflects the costs you reported. Misunderstandings or misinterpretations can occasionally lead to rejections.
- 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.
What are 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.
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.
A reimbursement claim in health insurance ensures that you can still receive coverage for eligible medical expenses even when a cashless claim is not available. Whether you receive treatment at a non-network hospital, face an emergency situation, or pay the hospital bills yourself for any reason, the reimbursement process allows you to recover covered expenses by submitting the required documents to your insurer.
To ensure a smooth claim experience, it is important to inform your insurer on time, keep all medical records and payment receipts safe, understand your policy coverage, and submit complete documentation within the specified timelines.
FAQs about Reimbursement Claims in Health Insurance
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. 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.
Can I file a reimbursement claim if cashless treatment was denied?
Yes. If your cashless claim request is declined or cannot be processed, you can pay the hospital bill yourself and later file a reimbursement claim, subject to policy terms and conditions.
Can reimbursement claims be filed for treatment at a network hospital?
Yes. Even if you receive treatment at a network hospital, you can file a reimbursement claim if you paid the hospital bills yourself instead of using the cashless facility.
Will I receive reimbursement for the entire hospital bill?
No, the insurer reimburses eligible medical expenses after considering policy coverage, exclusions, deductibles, co-payments, sub-limits, and the available sum insured.
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.
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.
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 24 hours of emergency hospital admission, or at least 48 to 72 hours before a planned hospital admission.
Can I file a claim for reimbursement costs that my policy does not cover?
No, you cannot file a reimbursement claim for the costs your policy does not cover. It is available only for expenses covered under your policy. Reimbursement may not be available for expenses that are specifically excluded from your policy.
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.
Is there a separate reimbursement form I need to fill out for Digit claims?
No, you need not fill out any form separately. You can file a reimbursement claim on the Digit app with all the required medical 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.