Reimbursement & Cashless Claims Procedure

Cashless Claim Process:

In order to avail the cashless claim facility, the insured has to be treated in an empanelled hospital. By providing the details of the health insurance policy and presenting the e-card or other physical proof of the health insurance taken in the name of the policyholder, he or she can avail cashless hospitalization and treatment, if the illness/ injury is covered under the policy. Once the patient is discharged from the hospital, all the medical bills are sent to the insurance provider by the hospital. The insurance provider then evaluates the expenses and settles the payment.

Reimbursement Claim Process:

The reimbursement claim for health insurance can be made if the policyholder opts to go to a hospital of his/ her choice, which is a non-empanelled hospital. In this case, the cashless claim facility cannot be used. Therefore, the insured has to pay all his/ her medical bills and other costs involved in hospitalization and treatment and then claim reimbursement. In order to avail reimbursement claim you have to provide the necessary documents including original bills to the insurance provider. The company will then evaluate the claim to see its scope under the policy cover and then makes a payment to the insured. In case the treatment is not covered under the policy, the claim will be rejected. The insurance provider generally provides reasons for the rejection.

Documentation:

The following documents are required in order to make a :

  • Duly filled claim form
  • Medical Certificate/ Form which is signed by the treating doctor.
  • Discharge summary or card (original), availed from the hospital.
  • All bills and receipts (original)
  • Prescription and cash memos from pharmacies/ the hospital.
  • Investigation report
  • If it is an accident case, then the FIR or Medico Legal Certificate (MLC) is required.

Recommended Posts