Health insurance is a valuable resource that helps individuals cover the costs of medical care. However, filing a claim can be a complicated and confusing process. A reimbursement claim is hospital bills first, and then your insurance company compensates you for it. When does this happen? When your hospital is not a part of our network of hospitals, you can apply for a reimbursement claim.
With the help of the expert, claims filing can be easier.
Step-by-Step Process to File a Reimbursement Claim
Step 1 – Gather Information and Documentation
Before filing a claim, you need to gather the necessary information and documents. This includes your insurance policy information, medical bills, receipts, and any other relevant documents. It's also important to understand what type of medical expenses are covered by your insurance policy.
Policy details and insured member information
Keep your policy number, the insured person’s name, and basic plan details handy, because you’ll need them at multiple points. If the policy covers family members, double-check you’re using the right insured member details before you begin.
Hospitalisation and treatment details
Note down admission and discharge dates, diagnosis, and the treatment/procedure performed. Having the doctor’s name, hospital name, and a quick summary of what happened makes form-filling faster and reduces back-and-forth later.
Step 2 – Understand Your Health Insurance Coverage
Understanding your health insurance coverage is critical when filing a claim. You should be aware of your insurance plan's deductibles, copayments, and out-of-pocket maximums. This information will help you estimate the amount you will need to pay out of pocket before insurance coverage kicks in.
Explore our Health Insurance Coverage
Check policy inclusions and exclusions
Before you submit anything, scan your policy for what’s covered and what isn’t. This avoids the frustrating situation of assuming a cost is covered, only to find out it falls under exclusions.
Verify sum insured and sub-limits
Make sure you know the available coverage left under your policy, especially if you’ve had prior claims. Also check sub-limits (like room rent caps or procedure limits), because these can affect how much you’re reimbursed.
Suggested Read: Sum Insured Vs Sum Assured
Confirm waiting periods
Some benefits only activate after a waiting period, especially for pre-existing conditions or specific treatments. If you’re unsure, it’s better to check first than to submit and then face a rejection you could’ve avoided.
Step 3 – Identify the Documents Required for Filing a Claim
Different insurance companies may require different documents to file a claim. Some common documents include medical bills, receipts, and a completed claim form. Be sure to check with your insurance company to identify the required documents.
Mandatory claim-related documents
These typically include the filled claim form, hospital bills, discharge summary, prescriptions, and diagnostic reports, and payment receipts. Keep photocopies (or scanned copies) ready because you may need to submit sets in a specific order.
Additional documents requested by insurers
Sometimes insurers may ask for extra documents like the doctor’s consultation notes, investigation reports, or a break-up of pharmacy bills. Don’t take this personally, it’s often just part of the verification process.
Step 4 – Collect Receipts, Bills, and Medical Records
Collecting receipts, bills, and other necessary documents is an important step in filing a claim. These documents will help prove that you have incurred medical expenses that are covered by your insurance policy.
Hospital bills and payment receipts
Make sure your final bill is itemized and matches the receipts you’re submitting. If any payments were made in parts (advance + final), keep proof for each transaction.
Prescriptions, diagnostic reports, and discharge summary
The discharge summary is one of the most important documents because it ties the diagnosis, treatment, and hospital stay together. Diagnostic reports and prescriptions support the medical necessity of the expenses you’re claiming.
Step 5 – Understand the Reimbursement Claims Process
Understanding the claims process can help you navigate the system and avoid any potential issues. The process typically involves contacting the insurance company, filling out a claim form, and submitting the form and supporting documents.
Timelines involved
Most claims have a submission window (often within days after discharge), so don’t wait too long. The sooner you submit, the sooner the review begins, and the fewer details you forget.
Verification and assessment procedures
Once received, the claim usually goes through checks for coverage, documentation, and medical necessity. If something doesn’t match up, the insurer/TPA may ask for clarification or additional documents.
Step 6 – Inform the Insurance Company
Contacting your insurance company is the first step in filing a claim. You can do this by phone, email, or through an online portal. The insurance company will provide you with the necessary forms and instructions to file a claim.
Claim intimation timelines
If possible, inform the insurer as early as you can, especially for planned hospitalization. For emergencies, inform them as soon as the situation stabilizes so your claim trail starts cleanly.
Modes of intimation (online, email, helpline)
Many insurers allow intimation through an app, website portal, email, or helpline. Choose the method that gives you a reference number or confirmation message, because that’s useful later.
Step 7 – Raise a Reimbursement Claim
Start by raising a claim. Fill out the claim form provided by the insurance company. This form will ask for information about the medical expenses you incurred and the services you received.
At ManipalCigna, you can raise a claim on the Medibuddy app or on the ManipalCigna Health Insurance website. So download the Medibuddy app and register with your policy number. Make sure you have all the necessary documents in hand to back your claim. Collect your hospitalization documents as proof and keep these documents until the claims process is completed. You can start the offline claim process by visiting the website and downloading the claim form.
Online vs offline claim initiation
Online is usually quicker and easier to track, especially if you already have scans of documents ready. Offline works well if you prefer submitting physical copies, but keep extra copies for your records.
Filling out the claim request
Fill the form carefully; small errors like a wrong policy number, mismatched dates, or missing signatures can slow things down. If a section doesn’t apply, mark it clearly instead of leaving it blank.
Step 8 – Submit the Claim Form and Supporting Documents
Within the next 15 days of discharge, submit the claim form along with supporting documents to the nearest ManipalCigna branch. Be sure to keep a copy of all documents for your records. The team at ManipalCigna will review the documents and process your claim.
How and where to submit documents
Submit documents exactly as instructed, whether via the app/portal upload or at the nearest branch. If you’re submitting physically, ask for an acknowledgment so you have proof of submission.
Importance of accurate and complete information
Incomplete documentation is one of the biggest reasons reimbursement claims get delayed. A clean, complete submission helps your claim move faster with fewer follow-ups.
Step 9 – Follow Up on Your Claim
Following up on your claim is important to ensure that it is being processed correctly. You can track the status of your claim through the insurance company's website or by contacting their customer service department.
Tracking claim progress
Don’t hesitate to check updates, especially if the status hasn’t changed in a while. Keeping an eye on progress helps you respond quickly if anything is needed.
Responding to insurer or TPA queries
If the insurer/TPA asks for clarification or extra documents, share them as soon as possible. Quick responses can prevent your claim from getting stuck in a “pending” loop.
Step 10 – Resolve Any Issues or Disputes
If there are any issues or disputes with your claim, it's important to address them promptly. Contact your insurance company and provide any additional information or documentation that is needed. The team at ManipalCigna will get in touch with you in case of incomplete or missing information.
Common reasons for claim delays or rejections
Delays often happen due to missing documents, mismatched details, or unclear bills. Rejections can also occur if the treatment isn’t covered, waiting periods apply, or disclosures were incomplete.
Grievance redressal mechanisms
If you feel something is off, raise a grievance through the insurer’s official channel. Keep your claim number and communication records handy so your concern can be reviewed faster.
Step 11 – Track the Status of Your Claim
Tracking the status of your claim helps you stay informed of any updates or changes. You can address any disputes promptly if any arise at this stage. The Medibuddy app is the most convenient way to track your claim status
Using insurer portals or customer support
Portals and apps are great for real-time status updates and document uploads. If you’re stuck, customer support can help clarify what’s needed and what stage your claim is in.
Expected settlement timelines
Settlement time can vary based on complexity and documentation completeness. Submitting everything correctly upfront usually means fewer queries and faster processing.
Conclusion
Reimbursement claims can feel paperwork-heavy, but once you break them into steps, they’re much more manageable. The goal is simple: submit the right documents, on time, with clear and accurate details.
With ManipalCigna, you also have multiple ways to initiate and track your claim, online through the MediBuddy app or the ManipalCigna website, and offline through branches, so you can choose what feels easiest.
FAQs
What is a reimbursement claim in health insurance?
A reimbursement claim is when you pay the hospital bills first and then submit documents to your insurer to get compensated, as per policy terms. This usually happens when treatment is taken at a non-network hospital.
What documents are required to file a reimbursement health claim?
Common documents include the claim form, itemized hospital bills, payment receipts, discharge summary, prescriptions, and diagnostic reports. Some cases may require additional documents depending on the treatment and insurer’s review.
What is the time limit to file a reimbursement claim?
Insurers usually have a specific submission window after discharge, often stated in the policy wording. It’s best to submit as early as possible to avoid missing deadlines and to reduce delays.
How long does it take to settle a reimbursement claim?
The timeline varies, but faster settlement usually happens when documents are complete, and details match the policy terms. If extra verification is needed, the insurer/TPA may take additional time.
What are the common reasons for rejection of reimbursement claims?
Rejections often happen due to missing documents, incorrect or mismatched details, waiting period restrictions, or expenses that fall under exclusions. Clear disclosures and a complete submission can prevent many of these issues.
