A health insurance policy, which does not provide the facility of cashless claim, will require the insured to settle the hospital bills directly on undergoing medical treatment. The same will apply if the individual is covered under a cashless facility but has been treated in a hospital not covered under the facility, or if the cashless request is turned down by the third-party administrator (TPA). In all such cases, the individual has to settle hospital dues upfront and then claim the reimbursement from the insurer.
A reimbursement claim form needs to be filled and submitted for processing to the insurance company if claims are processed in-house or are sent to the TPA. The form is usually is available with the TPA and insurer or can be downloaded from their websites.
The duly filled form should be accompanied by documents supporting the claim. These include original hospital bills and receipts, prescriptions, doctor's note for tests and investigations, details of operation performed and surgeon's bill, receipt, etc.
The claim is processed only after the form and all documents are received. It usually takes about 15-21 days for verification of the claim, ascertaining the eligibility and processing. The reimbursement cheque is then sent to the customer.
Points to note
1) Insurance companies may require intimation of hospital admission within the period specified.
2) The insurer will specify the period after discharge within which the reimbursement claim has to be submitted.
3) The company can deny the claim, fully or partially. In such a case, a letter giving the reason for the same is sent to the policyholder.