Health Insurance 319 views March 11, 2021

Health insurance claims can be made via cashless and reimbursement methods. But the first one applies to network hospitals only. In case any of the network hospitals of the insurer remains far away from your location, you will most likely go to non-network hospitals and pay for the expenses there. But with the reimbursement method, you can get back all the payment you do towards the treatment. So how is the reimbursement of health insurance processed? In reimbursement first, you need to pay the hospital bills from your pocket and get that reimbursed from the insurer.  When the insurer approves your claim request, you need to fill up a reimbursement claim form and submit the same along with some documents to the company’s branch office. You can download the reimbursement claim form from the company’s official website or visit any nearby branch office and collect the same. Let’s know more about the documents required for reimbursement of health insurance in this post below.

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List of Documents Needed for Reimbursement of Health Insurance

Duly Filled & Signed Claim Form

Under the reimbursement claim form, you need to fill in the following details –

  1. Policy number
  2. Certificate number
  3. Company or Third Party Administrator (TPA) ID number
  4. Name of the insured person under whose name the claim is being processed
  5. Current address, state or city name
  6. Enter the date of commencement.
  7. If you have any other health insurance/Mediclaim policy, enter the company name, policy number and sum insured
  8. If you are hospitalized in the last 4 years, enter the date and diagnosis
  9. If you are previously covered under health insurance, enter that insurance company’s name
  10. After that, enter hospitalization details like – the name of the hospital, room category, date and time of admission, date and time of discharge, a system of medicine
  11. Enter the details of the claim, such as the total cost of pre-hospitalization, hospitalization, post-hospitalization, health check-up, ambulance charge and other medical expenses.
  12. Enter PAN number, bank account number, bank name and branch name, IFSC code
  13. Enter the date of submitting the reimbursement form, enter the place, and sign the claim form where the box stating the signature of the insured is mentioned

Discharge Summary (Obtained from the Treating Hospital/Nursing Home)

The insurer requires the original hospital discharge summary because it contains the following information –

  1. Reasons for hospitalization such as the patient’s primary condition for hospitalization, including the description of the initial diagnostic tests
  2. The discharge summary also contains information on the procedures and treatment provided by the hospital
  3. And at last, the patient’s discharge condition is mentioned with which the insurer knows the insured’s health status on discharge.

Hospital Final Bill

The hospital final bill contains the detailed breakup of room rent, nursing and other services expenses such as –

  1. Name of Patient
  2. Age/Sex
  3. Address
  4. Date and Time of Admission
  5. Date and Time of Discharge
  6. Name of Treating Doctor
  7. Diagnosis of illness or injury
  8. Room Rent charge
  9. Nursing charges
  10. RMO charges
  11. IV Fluids administration charges
  12. Blood Transfusion administration charges
  13. Injection charges
  14. ICU Rent
  15. ICU Nursing charges
  16. ICU RMO charges
  17. Surgeon charges
  18. Anesthetist Charges
  19. Medical Practitioner charges
  20. Consultants charges
  21. Specialist Charges
  22. Fee for anesthesia, blood, Oxygen, Operation Theater charges, surgical appliances, diagnostic materials, general investigations, specialized investigations, dialysis, chemotherapy, radiotherapy
  23. Cost of artificial limbs and implants
  24. Patient paid amount
  25. Balance amount

Investigation Reports

You need to submit all the investigation reports of the diagnostic tests of the injury or illness for which you have been admitted to the hospital. This includes – X-ray, blood tests, urine tests, ultrasound, etc.

Implant sticker/invoice

The insured needs to submit the implant sticker/invoice in case of self-purchase of implants for – Cataract, Heart surgeries, AbdominalSurgeries, Knee replacement surgeries, etc. For this, vendor invoice and payment receipt shall also be required.

Previous Treatments Documents, if any

If the insured person has any pre-existing condition and has been treated for the same, they also need to submit the investigation reports for the previous treatment for reimbursement of health insurance.

Medico-Legal Certificate (MLC) or First Investigation Report (FIR)

MLC or FIR is mandatory for accidents, burns, suicide, poisoning and other injury cases. And if you haven’t done MLC or FIR, in such cases, the same should be given in writing by the hospital authority.

National Electronic Fund Transfer (NEFT) Details

Provide your NEFT details such as bank account number, IFSC code, bank name, bank branch name to the insurer, so the insurer can reimburse health insurance claims.

Note– The insurer may ask for additional documents as well if the claim demands further investigation

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