Top 10 Checklists for Reimbursement Claim

Introduction

There are two types of claims in Health Insurance. First, a Cashless claim is available on going to the insurance company’s network hospital for treatment, in which there is no need to pay money for any treatment at your hospital, the hospital takes the cost of this treatment from the insurance company. And second one is reimbursement, here we will try to know about the activity related to reimbursement claims.

As per the Mint article  total no of cashless claims in health insurance is just 32% only the rest of the reimbursement claims, it doesn’t matter how many network hospital insurers have, but most of the claims about reimbursement rather than cashless

There can be some important reasons behind this, like as per the agreement between Network Hospital and Insurer, a limit has been set on the cost of treatment and the hospital tells the insured person that it has seen, the insurance company is cashless only for you. X amount of particular treatment will be approved, the rest you will have to pay from your pocket, and if you pay for the treatment here, you can recover it by claiming reimbursement from the insurance company.

This kind of situation is created by the hospital in a fake form in which they get more money from their insurer than the MOU and immediately get it in the form of cash from the insured person, there is no question of any credit too.

Now, take the example from the insurer- Sometimes Insurance companies deny cashless claims, due to various reasons like, document discrepancies, statement mist-match by the insured person, PED mentioned on treating doctor’s note and the same was not informed to the insurer by an insured person at the time of policy buying, admission not justified etc. Please refer link for details information about the claim rejection reason

Now, take the example from an insured person- Sometimes policyholders don’t want to take a cashless claim and prefer a reimbursement claim instead, due to various reasons like good and reputed hospitals nearby policyholders and the particular hospital not in-network list of insurance companies; might be any personal or professional relationship between the policyholder and hospital representatives; for fraudulent claim activity by policyholder and hospitals

For Pre & Post Hospitalization claims of IPD cashless cases

From all these examples it becomes clear why a reimbursement claim is necessary for health insurance, now we know how the reimbursement claim is filed and what documents are to be attached.

It is very important to check with the respective insurance company website whether the hospital where insured members need to be treated that hospital is backlisted with the insurance company or not if the hospital is backlisted hospital then reimbursement claim will be paid only for extreme medical emergencies, if the hospital is not their insurer backlist then the policyholder need to inform over insurance company customer care no that insured person going to admit for particular reasons/treatment

In this situation, policyholders are advised to file a reimbursement claim, here are the main top 10 checklists that will help you get the least hassle in claiming your reimbursement: –

Reimbursement Form of Insurance Company –

It is the Hospital’s responsibility to fill out the complete reimbursement claim form of the insurance company and sign and stamp it accordingly.

Hospital Discharge Summary –

The treating hospital will provide a Complete Discharge summary with the mentioned treating doctor’s note / complete investigation/treatment details/ past medical history since when if any, justified condition notes

Hospital Main Bills –

All the bills, main bill, and itemized bills need to be provided by the hospital these bills need to be justified the complete course of treatment

Investigations Reports –

All types of justified investigation reports, like pathology, radiology, sonology reports etc.

Pharmacy Bills –

All justified pharmacy bills.

KYC–

Know Your Customer documents of the proposer and the insured person.

ICP–

Indoor Case Paper, usually hospital does not provide the original copy of the same, in this case asked for verified copies, ICP paper is the medical notes/treatment notes and it is complete notes of the line of treatment

MLC Report/ Police FIR–

When admitted into hospital for any kind of accident, any physical assault, wherever necessary

Bank Account Proof –

Proposer Bank proof also needs to be attached

Any other–

Based on case to case, policyholders need to submit the additional letter and declaration.

This is the indicative top 10 list of reimbursement claim checklist, it might be asked for further documents from the insurance company depending upon the case with the exact reason mentioned in the Query letter.

Policyholders can file their claim online or visit the branch, if the branch representative will not accept your claim application, then you can be asked to issue a “Non-Acceptance Memo”.

TAT–

For reimbursement claim TAT, it depends upon the insurance company to the insurance company and around 7-15 working days from the date of acceptance of the claim application, and the insurance company will reply within the timeline, whether to accept or whether to reject or whether to ask for further documents