What Is Reimbursement Claim In Health Insurance?

A reimbursement claim in health insurance allows policyholders to pay medical expenses upfront and get reimbursed later. Learn about its process, benefits, and key factors.
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3 min
27-March-2025

Health insurance is essential for managing medical expenses in India. While cashless claims are popular, many policyholders opt for reimbursement claims, especially when treatment is taken at a non-network hospital. In a reimbursement claim, the policyholder pays the hospital bills upfront and later gets the amount reimbursed by the insurer.

Filing a reimbursement claim requires proper documentation, adherence to timelines, and compliance with policy terms. Many claims are delayed or rejected due to missing paperwork, policy exclusions, or incorrect submissions. Understanding the process, required documents, and potential pitfalls can help ensure a smooth claim settlement.

This guide provides a detailed overview of how reimbursement claims work, the step-by-step process, required documents, and tips to avoid rejection. It also compares cashless vs reimbursement claims, helping policyholders make informed decisions when choosing a health insurance plan.

How does a reimbursement claim work in health insurance

A reimbursement claim allows policyholders to claim back medical expenses incurred at hospitals that are not part of the insurer’s network hospitals. Unlike cashless claims, where the insurer directly settles bills with the hospital, here, the policyholder pays first and then submits a claim for repayment.

Process of a reimbursement claim

  1. Hospitalisation and payment – The insured undergoes treatment and settles all hospital bills.
  2. Collect necessary documents – All original invoices, prescriptions, and reports must be collected.
  3. Claim submission – The insured submits a claim form along with supporting documents to the insurer.
  4. Insurer review – The insurer verifies the claim to check compliance with the policy.
  5. Approval and payment – Once approved, the amount is reimbursed as per the policy terms.

Key points to remember

  • Claims must be filed within the stipulated time mentioned in the policy.
  • Non-admissible expenses such as personal items, non-medical costs, or policy exclusions will not be reimbursed.
  • The reimbursement process may take 7-30 days, depending on the insurer’s claim approval procedure.

Pro Tip

A comprehensive health plan not only covers hospitalization but also pre & post-treatment expenses, ensuring complete financial protection against rising medical costs.

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Steps to file a reimbursement claim successfully

To ensure a smooth reimbursement claim process, follow these steps:


1. Get treated at a non-network hospital

Choose a hospital of your choice for treatment. Unlike cashless claims, you can get treated anywhere, even if the hospital is not in the insurer’s network.

2. Pay the bills and collect original documents

After discharge, settle the hospital bills yourself and gather all necessary paperwork, including the discharge summary, invoices, medical prescriptions, and diagnostic reports.

3. Fill out the reimbursement claim form

Download the reimbursement claim form from your insurer’s website and fill in the required details accurately. Errors can lead to claim rejection or delays.

4. Submit the claim along with supporting documents

Send the filled claim form along with original documents to the insurer via email or courier. Some insurers also allow online submission through customer portals.

5. Follow up on claim status

After submission, monitor your claim status via the insurer’s website or customer support. If additional details are required, respond promptly to avoid delays.

6. Receive reimbursement

Once the insurer processes and approves the claim, the reimbursement amount is transferred to your bank account as per the policy’s terms and conditions.

Key documents required for a reimbursement claim

Providing the right documents is crucial for a smooth claim settlement. The required documents include:

  • Duly filled reimbursement claim form (available on the insurer’s website)
  • Original hospital bills with itemised charges
  • Doctor’s prescription and treatment summary
  • Discharge summary from the hospital
  • Diagnostic test reports (X-rays, MRIs, blood tests, etc.)
  • Pharmacy bills with doctor’s prescription
  • Cancelled cheque or bank account details for reimbursement
  • Policyholder’s ID proof (Aadhaar, PAN, or passport)
  • Insurance policy copy

Keeping duplicate copies of these documents is recommended in case they are needed for future reference.

Common reasons for reimbursement claim rejection

Several factors can lead to claim rejection, including:

Incomplete documentation – Missing or incorrect forms and bills can delay or reject claims.


Treatment not covered – If the treatment falls under policy exclusions, the insurer may not approve the claim.


Delayed claim submission – Claims must be filed within the stipulated timeframe, typically 30-90 days.


Pre-existing condition waiting period – Some treatments may not be covered if they fall within the waiting period.


Incorrect or mismatched details – Discrepancies in patient details or policy numbers can lead to rejection.


Non-admissible expenses – Costs like registration charges, personal items, and dietary supplements are often excluded.

Cashless vs reimbursement claim which one to choose

Both cashless and reimbursement claims offer financial support but work differently.

Cashless claims

  • The hospital directly bills the insurer.
  • Available only in network hospitals.
  • No need for upfront payments.
  • Quick and convenient process.

Reimbursement claims

  • The policyholder pays first and claims later.
  • Applicable for both network and non-network hospitals.
  • Requires document submission and insurer approval.
  • Takes longer for processing compared to cashless claims.

Which one to choose?

  • If you prefer hassle-free treatment with zero out-of-pocket expenses, cashless claims are the better option.
  • If treatment is at a non-network hospital or in emergencies, reimbursement claims provide flexibility.    

Tips to get a reimbursement claim approved faster

Follow these tips to avoid delays or claim rejections:

  • Ensure complete documentation – Submit all original bills, prescriptions, and medical reports.
  • File the claim on time – Most insurers require claims to be filed within 30-90 days after treatment.
  • Check policy exclusions – Ensure the treatment is covered before filing a claim.
  • Provide accurate details – Mistakes in policy number, insured name, or hospital details can lead to rejection.
  • Follow up regularly – Track your claim status online or contact customer support for updates.
  • Consult the insurer beforehand – If unsure about coverage, inform the insurer before hospitalisation to clarify eligibility.

Conclusion

Filing a reimbursement claim in health insurance requires careful documentation and adherence to insurer guidelines. Unlike cashless claims, reimbursement involves paying upfront and seeking repayment later. While this process gives flexibility in choosing hospitals, it requires proper record-keeping and timely submission.

To ensure quick and hassle-free approvals, policyholders should submit complete documentation, check policy coverage, and follow up on claim status. Choosing between cashless and reimbursement claims depends on hospital preferences and policy terms.

Understanding the reimbursement claim process helps policyholders avoid common pitfalls, ensuring smooth claim settlement and financial protection during medical emergencies.For those seeking a convenient and reliable way to explore health insurance plans, consider Bajaj Finance Insurance Mall. We partner with numerous insurers, providing a diverse selection of health plans to cater to varying needs and budgets. Our online platform allows you to effortlessly compare policies, and select the ideal plan to safeguard your health and finances. With Bajaj Finserv, securing the right health insurance coverage is a hassle-free and informed decision.

Frequently asked questions

What is the difference between cashless and reimbursement claims in health insurance?
A cashless claim allows policyholders to get treatment at network hospitals without paying upfront, as the insurer settles the bill directly. In a reimbursement claim, the policyholder pays first and later submits bills for repayment. While cashless claims are quicker, reimbursement claims offer flexibility in hospital choice but require detailed documentation.

How long does it take to get a reimbursement claim approved?
The approval process for a reimbursement claim typically takes 7 to 30 days, depending on the insurer. If documents are complete and policy terms are met, approval is faster. However, missing paperwork, incorrect details, or further verification requirements may cause delays. Timely submission and accurate documentation help in quick claim processing.

What expenses are covered under a reimbursement claim?
Reimbursement claims cover hospitalisation expenses, including room rent, doctor’s fees, surgeries, medicines, diagnostic tests, and ambulance charges. Some insurers also include pre- and post-hospitalisation costs. However, non-medical expenses like consumables, registration fees, and administrative costs are usually not reimbursed. Checking policy terms helps understand the exact coverage.

Can a reimbursement claim be rejected If yes why?
Yes, a reimbursement claim can be rejected due to incomplete documentation, policy exclusions, delayed submission, pre-existing condition waiting periods, or incorrect details. Expenses not covered under the policy, such as non-admissible charges, may also lead to rejection. Ensuring accurate paperwork and timely submission reduces the risk of claim rejection.

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