To file a reimbursement claim under group health insurance, you pay the medical bills yourself first, then claim the amount back from your insurer or third-party administrator (TPA). You do this by submitting a filled claim form along with the required documents, such as the discharge summary, hospital bills, prescriptions and diagnostic reports, within the timeline specified in your group health insurance policy, commonly within 15 to 30 days of discharge. The insurer verifies the documents and credits the approved amount to your bank account.
When Should You File a Reimbursement Claim Under Group Health Insurance?
In Group Health Insurance, file a reimbursement claim when you have incurred the medical expenses covered under your policy as part of your treatment. This typically happens in these situations:
You were treated at a hospital outside the insurer's network, where cashless facility is not available.
You did not, or could not, get cashless pre-authorisation approved before or during the hospital stay, often in an emergency.
The cashless request was declined, so you paid out of pocket and now want the eligible amount back.
You are claiming pre-hospitalisation and post-hospitalisation expenses, such as consultations, diagnostic tests and medicines before admission or after discharge, which are often claimed separately through reimbursement.
In a reimbursement claim, you settle the entire bill with the hospital, and the insurer pays you back afterwards based on what your group health policy covers.
Here's an Example:
For example, say you are travelling and suddenly need to be admitted to a nearby hospital that is not on your insurer's network list. Since cashless is not available there, you pay the hospital bill yourself, collect all the bills, discharge summary and reports, and submit them to your insurer. The insurer then reviews your documents and pays back the eligible amount as per your group health policy.
How Do You File a Reimbursement Claim Under Group Health Insurance?
Inform the insurer or TPA
Notify the insurer or TPA about the hospitalisation. For planned treatment, intimate them before admission. For an emergency, inform them within the timeline specified in your policy, commonly within 24 to 48 hours of admission.
Pay the hospital and collect documents
Settle the hospital bill at discharge and collect all original documents: final bill, discharge summary, prescriptions, reports and payment receipts.
Fill the reimbursement claim
Complete the insurer's claim digitally or via a form with patient details, policy or employee ID, diagnosis, and bank details for the payout.
Submit the claim
Send the claim form and all documents to the TPA or insurer, online through the portal or app, or physically to the claims address, within the deadline.
Track and respond to queries
Note your claim reference number, track the status, and quickly supply any extra documents the insurer asks for.
Receive the settlement
Once approved, the insurer credits the eligible amount to your registered bank account, after applying any deductions.
What Documents are Required for a Reimbursement Claim Under Group Health Insurance?
Reimbursement claims require specific documents and proof to be submitted for successful claim settlement by the insurer.
| Document | Why it is needed |
|---|---|
| Discharge summary | Confirms diagnosis, treatment and dates of admission and discharge |
| Original hospital bills and payment receipts | Proves the amount you actually paid |
| Doctor's prescriptions and consultation notes | Links tests and medicines to the treatment |
| Diagnostic and investigation reports | Supports the medical necessity of the treatment |
| Pharmacy bills with prescriptions | Substantiates medicine costs claimed |
| Identity proof and policy or employee e-card | Confirms you are covered under the group policy |
For pre-hospitalisation and post-hospitalisation expenses, attach the related consultation slips, prescriptions, lab reports and bills, since these are claimed separately from the main hospital bill.
Submit original documents and keep copies
Submit original documents and keep copies
Reimbursement claims generally require the original documents or scanned copies of the original documents, as specified by your insurer or TPA. Before you hand over the originals, make a complete set of copies for your own records and for any tax or top-up claims. Once submitted, originals are typically not returned.
What are the Timelines for Filing a Reimbursement Claim Under Group Health Insurance?
Claim settlement depends on when you two main timelines: intimation (informing the insurer about the hospitalisation or procedure) and document submission for filing the claim.
Here's what you need to keep in mind:
Intimation for planned treatment: usually before admission.
Intimation for emergencies: typically within 24 to 48 hours of admission.
Document submission: commonly within 15 to 30 days of discharge for the main claim.
Post-hospitalisation bills: often claimable within a window after discharge (for example up to 60 or 90 days), depending on the policy.
The exact durations may vary by group health insurance policy and insurers. Make sure you read them in your policy document or with your HR team or TPA. Insurers settle approved claims within the period set by the Insurance Regulatory and Development Authority of India (IRDAI) rules and the policy terms.
What are the Common Reasons for Group Health Insurance Reimbursement Claim Rejection?
Most claim rejections and delays are due to missing, incorrect or incomplete documents and timelines. The most common reasons are:
Missing or incomplete documents: A claim with no discharge summary, doctor's note and diagnosis, missing reports or bills.
Submitting photocopies or uncertified copies: If your insurer or TPA requires original documents or scanned copies of the original documents and you submit photocopies or uncertified duplicates instead, your claim may be delayed or rejected.
Filing after the deadline: Every group health policy sets a window for intimating the insurer and submitting documents. Beyond that window without a valid reason, such as a medical emergency, may lead to insurance rejection.
Excluded treatments or items: Group health policies may not cover certain procedures, consumables and conditions. Claiming for something the policy excludes leads to claim rejection
Claiming during a waiting period: Specific conditions, like pre-existing illnesses or certain surgeries, are covered only after a waiting period ends. A claim raised before that period is over will be denied.
Mismatched details across documents: If the name, dates, diagnosis or amounts differ between your bills, reports and discharge summary, the insurer flags it for inconsistency and may reject the claim
No timely response to queries: In case the insurer asks for additional documents or clarification, you usually get a set number of days to reply. Ignoring that request or replying late can lead to the claim being closed.
If a claim is rejected, the insurer must give a reason in writing. You can submit the missing documents, ask for a reconsideration, or escalate to the insurer's grievance officer, and ultimately the Insurance Ombudsman, if you believe the rejection was incorrect.
Learn more about Cashless vs Reimbursement Health Insurance Claims.
Key Takeaways
A reimbursement claim means you pay the hospital first and the insurer repays the eligible amount afterwards.
It is used mainly at non-network hospitals or when cashless approval was not obtained.
Intimate the insurer or TPA before planned admission, or within 24 to 48 hours in an emergency.
Submit the claim form with original bills, discharge summary, prescriptions and reports, usually within 15 to 30 days of discharge.
The payout can be reduced by co-payment, non-payable items, room-rent limits and sub-limits.
Most rejections are due to missing documents, photocopies instead of originals, or missed deadlines.
Confirm exact timelines, co-payment and exclusions in your specific group policy or with your HR team or TPA.
Frequently asked questions
You cannot claim the same expense twice. However, you can use cashless for the main hospital bill and reimbursement for separate pre-hospitalisation and post-hospitalisation expenses that were not part of the cashless settlement, as long as each cost is claimed only once.
Sources and references
- 1.Insurance Regulatory and Development Authority of India (IRDAI) - Health insurance regulations and claim settlement guidelinesRegulator for insurance claim processes and timelines in India
About the authors
Neviya Laishram
Written by · Senior Editor
Nitesh Kapur
Reviewed by · Senior Director – Underwriting & Claims, ACKO Group Health Insurance
