How To Reimburse Mediclaim During An Emergency: A Step-By-Step Guide

Health Insurance

An indemnity cover, also called Mediclaim, comes into effect during a medical emergency such as accidents, hospitalisations and treatment for critical illnesses. Depending on a policy’s terms and conditions, the insured can claim reimbursement for certain medical expenses. This article takes you through the Mediclaim reimbursement process to help you navigate through the claim filing with ease. Read on!  

What is Mediclaim Reimbursement?

There are many times when patients or their families pay the bills from their pocket. After the payment, they contact the insurance companies for reimbursement. This process is known as Mediclaim reimbursement. This process is helpful especially during an emergency when there’s less time to look up Network Hospitals for cashless claims. 

When Can you Opt for Mediclaim Reimbursement?

The mediclaim reimbursement will be applicable only in the following two instances:

• When the policyholder gets admitted to a non-network hospital out of compulsion, or, 

• If there is no provision for a cashless facility

How to Choose a Credible Insurer for Your Mediclaims?

Given below are the points that one needs to consider before choosing an insurer for investing in a Mediclaim:

• Sum insured – Medical expenses have skyrocketed due to medical inflation. So, one should choose a Mediclaim with maximum coverage.

• Coverage – The Mediclaim should cater to the medical needs of the family. It would be useful if any family member falls ill. 

• Claim settlement procedure – It is important to see whether the insurance company provides a smooth claim settlement process. This is because it will be difficult to run around claiming the money when the insured person is hospitalised. 

• Cashless facility – The Mediclaim should have a cashless facility. It greatly simplifies the claim settlement procedure and saves valuable time for the insured and his/her family. 

• Network hospitals – It is important to opt for a Mediclaim which provides wide coverage of network hospitals across cities. 

• Compare Mediclaims online – One can compare the terms and conditions of various Mediclaims online, before choosing the one most suitable.

How to File a Mediclaim Reimbursement Claim During an Emergency?

Sometimes, people just do not have enough time to file claims early due to medical emergencies. Hence, insurers allow people to file cashless claims even after hospitalisation. 

Given are the steps you can undertake to make claims during medical emergencies:

1. After emergency hospitalisation, go to the insurance desk in the hospital. 
2. Make sure to take not more than a few hours for the intimation.
3. Show the insured patient’s health card and identity proof.
4. Fill up the pre-authorisation form at the insurance desk.
5. Your insurer or TPA will authenticate the cashless claim request and send an authorisation letter to the hospital for policy coverage.
6. Make sure to cooperate with the hospital regarding your policy coverage to avoid any confusion.

If you are too late to file for cashless claims, you should make sure to have all the original medical bills and file for a reimbursement.

Documents Needed for the Mediclaim Reimbursement Process

Check if you have the following documents before filing a claim:

• Valid ID proof (Aadhaar card, PAN card, etc.)
• A medical certificate signed by one’s treating doctor
• Discharge summary or certificate from the hospital
• Signed claim form
• Original pharmacy bills
• Original policy documents 
• Prescriptions and cash memos from the hospital
• Diagnostic reports
• For accidents, FIR or MLC (Medico-Legal Certificate)
• Ambulance receipt (if applicable)

How to Check the Status of Your Reimbursement Claim?

The steps to check the status of your reimbursement claim are given below.

Online: 

Step 1: Go to the official website of the Mediclaim provider.

Step 2: Click on ‘Register a Claim’.

Step 3: Next, click on ‘Track Claim’.

Step 4: You’ll be redirected to a page where you need to provide your date of birth, customer ID, claim number and Mediclaim number.

Step 5: Hit ‘Submit’. The claim status will be displayed.

Offline: 

Step 1: Visit the nearest branch of your Mediclaim provider with all the important documents.

Step 2: You can call up the customer care number to enquire about the status of your reimbursement claim

Step 3: You can mail your enquiries as well. Make sure you provide the mediclaim policy number and other relevant details

Reasons your Reimbursement Claim can get Rejected

Given below are the top reasons why a Mediclaim reimbursement claim can get rejected:

• If the policyholder has filled up the reimbursement claim form incorrectly.

• If the claim was filed after the stipulated time period.

• If the insured patient did not really need the treatment/medical procedure.

• If the disease against which the policyholder is making the reimbursement claim isn’t covered by the Mediclaim.

Also Read: Understanding Health Insurance Claim Settlement Ratio In India

What Can You Do in Case of a Claim Rejection?

If your insurance claim is rejected, you can take the following actions to amend it:

Figure out the reason behind rejection

Before taking any action, try to figure out your mistake with the claim filing. Providing wrong information, making claims outside the policy coverage, or lack of necessary documents are some common reasons behind this. 

File the claim again

If your claims had incorrect information, you could ask your insurer about reinitiating the mediclaim reimbursement process. Take a look at what went wrong and make sure to not repeat the mistakes.

Communicate with the TPA

TPA representatives help with processing claims and assist policyholders. Contact him/her to help you with a solution and reopen the claim case to correct errors.

Submit all necessary documents

For smooth settlement, the insurer will require hospital bills, discharge summary and prescriptions. You will need to double-check if you have submitted all of these documents to the insurer/TPA.

Make multiple appeals

If you have all the required documents to support your claim, you can send a formal letter with evidence about why your claim is valid. You can make multiple claim appeals or send your consulting doctor’s statement as further proof.

Also Read: 10 Best Health Insurance Policies In India:  Benefits, Coverage, Exclusion And How To Choose A Policy

Things to Keep in Mind Before Filing a Reimbursement Claim

Given below are the things that one needs to keep in mind before filing a reimbursement claim:

• Informing the insurance company – The policyholder needs to inform the insurance provider about emergency hospitalisation/need for medical attention at the earliest. 

• Proper communication – Clear two-way communication is essential for filing a reimbursement claim. This is important for getting accurate information about the process of filing a claim. 

• Tenure – Insurance companies will not entertain claim requests for expired Medicalims. So it’s important to be aware of the tenure of the mediclaim. 

• Terms and conditions – One needs to minutely go through the terms and conditions of a Mediclaim. This is necessary because insurance companies won’t cover medical conditions/diseases not stated in the Mediclaim. 

Final Word

Insurance agencies provide the option to get cashless claims or get compensated later. How long the mediclaim reimbursement process takes will depend on the insurer. Insurance companies that settle claims without hassles have a very high claim settlement ratio, indicating their commitment to helping customers.

Navi Health Insurance offers a very simple claims process and has an industry-leading claim settlement ratio of 97%. Download the Navi App from the Google Play store and get a policy that will settle cashless claims in only 20 minutes.

FAQs on Mediclaim Reimbursement Process

Before you go…

How about an affordable health insurance policy 👨‍⚕️ starting at a monthly premium of just ₹235? Install the Navi app now and get your policy in under 2 minutes.

Disclaimer: This article has been prepared on the basis of internal data, publicly available information and other sources believed to be reliable. The information contained in this article is for general purposes only and not a complete disclosure of every material fact. It should not be construed as investment advice to any party. The article does not warrant the completeness or accuracy of the information, and disclaims all liabilities, losses and damages arising out of the use of this information. Readers shall be fully liable/responsible for any decision taken on the basis of this article.