Reimbursement Health Insurance
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Claim settlement is one of the critical factors in a health insurance policy because Health Insurance is all about providing a financial backup during medical emergencies. There are mainly two types of claims in health insurance: cashless and reimbursement. In this article, let’s throw light on the key features and benefits of Reimbursement Health Insurance.
What is reimbursement in health insurance?
The word reimbursement refers to the action of repayment to a person who has spent or lost money. In health insurance, it is a type of claim settlement wherein you have to pay the medical/hospitalisation bills for the availed medical treatment. Later, you can get it reimbursed from your insurer, in this case ACKO.
Types of health insurance claims:
Cashless Claim:
In a cashless claim, the policyholder seeks medical treatment at a network hospital or healthcare facility recognized by their insurer.
The hospital, after obtaining pre-authorization if necessary, directly bills the insurance company for the covered medical expenses.
Policyholders are not required to pay for covered expenses upfront in most cases, except for any co-payments, deductibles, or non-covered charges as per their policy.
This type of claim is convenient for planned treatments and emergencies, as it minimizes the immediate financial burden on the policyholder.
Reimbursement Claim:
In a reimbursement claim, the policyholder receives medical treatment at any hospital, whether it's in the insurer's network or not.
After treatment, the policyholder pays for the medical expenses out of pocket and collects all relevant bills, receipts, and medical records.
The policyholder then submits a claim to their insurance company, providing all necessary documentation.
The insurance company reviews the claim, verifies the expenses, and assesses whether they are covered as per the policy terms.
If the claim is approved, the insurer reimburses the policyholder for the covered expenses, either partially or in full, depending on the policy's coverage and limits.
Policyholders are responsible for the initial payment of medical bills in reimbursement claims, and the reimbursement is typically made after the claim is processed.
Key Features and Benefits of Reimbursement Health Insurance
Reimbursement Health Insurance is nothing but a health insurance plan with a reimbursement claim facility. One of the critical features of such a claim settlement option is the flexibility of availing of medical treatment at your desired hospital. The hospital need not be empanelled with ACKO to avail the benefits of the medical insurance. Here are the benefits of such a health insurance claim settlement.
Need not worry about locating a network hospital during medical emergencies.
Can avail treatment from any hospital (non-network hospital).
Need not go through any health insurance-related procedures while availing of medical treatment.
Can apply for a claim once the medical treatment is availed and the bills are settled.
What is Covered in a Reimbursement Health Insurance?
The coverage offered by a health insurance policy remains the same irrespective of the claim settlement method. Here are the coverage benefits of a Reimbursement Health Insurance.
Covers hospitalisation expenses
It covers pre- and post-hospitalisation expenses
Covers cost incurred due to daycare treatment
It covers critical illnesses such as stroke, cancer, paralysis, etc.
OPD treatment (Depends on the terms and conditions of the policy)
Covers the cost of transportation of the insured patient via ambulance in a medical emergency
Reimbursement Health Insurance Claim Settlement
You can use the reimbursement claim settlement facility if you wish to opt for a hospital of your choice. You can avail of the medical treatment and settle the hospital bills first before applying for a claim.
For raising a claim, you need to furnish all the required documents such as original hospital bills, pharmacy bills, doctor certificates, etc.
After verifying the documents, ACKO will settle the claim provided the claim meets all the terms and conditions and is under the scope of coverage of the health insurance policy. Post the approval of the claim, ACKO will make the payment to the insured.
Reimbursement Hospitalisation Claim Process
Here are the steps involved in making a reimbursement hospitalisation claim.
Inform ACKO about the medical treatment and the details of the hospital.
Avail of medical treatment at your desired hospital.
Settle the hospitalisation bills.
Apply for the claim online or by writing to us.
Share all hospitalisation-related documents.
Upon verification of the documents and scope of coverage, ACKO will make the payment to the insured after excluding the deductibles.
How does a Reimbursement Health Insurance work?
The Health Insurance Reimbursement is nothing but a health insurance policy that provides reimbursement claim settlement. So, the policy's overall coverage benefits and facilities will remain the same as for cashless treatment. The only difference is that you can avail of medical treatment at the hospital of your choice, and you have to clear the hospital bills on your own before applying for a claim. The rest of the terms and conditions of the policy will remain the same.
Documents Required for Reimbursement Claim
Here is the list of required documents to apply for a reimbursement claim.
Duly filled and signed claim form
Medical certificates signed by the doctor
Original discharge summary
All original hospital bills
Original prescriptions and pharmacy receipts
Diagnostic reports/lab reports
FIR or Medico-Legal Certificate (in case of an accident)
Cashless claim in health insurance
Cashless claim or cashless hospitalisation is a hassle-free claim facility provided by ACKO wherein the insured can avail treatment at a hospital without making any payment. But the insured or any covered member must avail of the medical treatment in a network hospital. The medical expenses will be paid by ACKO directly to the hospital after verifying the coverage limits of the health policy and applicable deductibles.
Also, read: Types of Health Insurance in India
Network and non-network hospitals
A network hospital refers to a hospital that is partnered with ACKO to offer a cashless treatment facility. You can view the list of ACKO network hospitals by logging in to your account via the website or mobile app. Non-network hospitals are those hospitals that have not partnered with ACKO. You can opt for a non-network hospital if you are planning for reimbursement hospitalisation. Such hospitalisation requires you to clear the hospital bills before you apply for a claim.
Factors You Should Consider Before Opting for Reimbursement Claim
Understand Your Coverage
Carefully go through your insurance policy or company guidelines. Understand what kinds of expenses are covered. Ensure that your expense matches the categories mentioned. Knowing your coverage is like having a roadmap for your claim journey.
Maintain Records
Be diligent about maintaining records. Safeguard all your receipts, invoices, and bills. These documents are essential when it comes to proving your expenses. They come in handy in any kind of emergency.
Be mindful of the deadline
Pay attention to submission deadlines. Missing them could mean missing out on your reimbursement. Keep a calendar or set reminders to ensure you don't forget. Time can be your best friend or your worst enemy in this process.
Count the Costs
Calculate the total cost of your expenses. Ensure that it falls within the maximum limit set by your policy or company. Going over the limit might mean having to cover the excess yourself. It's simply sticking to a budget.
Exclusions Exist
Check for exclusions in your policy. Some expenses, like elective cosmetic treatments, may not be eligible for reimbursement. Understanding these exclusions helps manage expectations.
Claim Process
Understand the journey your claim will take. Most likely, it involves submitting your documents, having them reviewed, and waiting for approval. It lays down a step-by-step process to get through the overall process.
Wait Periods
Some policies have waiting periods. During this time, certain expenses may not be eligible for reimbursement. Be patient and plan accordingly.
Tax Check
Know your taxes well. Know how your reimbursement might affect your taxes. Some reimbursements are taxable, while others are not. Understanding the tax implications can help you make informed financial decisions.
Priority Check
Consider the urgency of your expense. Some require quick reimbursement, like medical bills, while others can wait, like business expenses. Prioritizing helps you manage your finances efficiently.
Alternatives
Explore other options available to you. Your company might offer a credit card for business expenses or a direct billing system for medical costs. These alternatives can simplify the reimbursement process.
Policy Updates
Stay informed and up to date about any changes in your policy. Policies can evolve over time. Keeping up with updates ensures you're aware of any new guidelines or benefits.
Manage Your Finances
Think about the financial impact of your expenses. Make sure you have the means to cover it temporarily until you receive your reimbursement. Managing your finances wisely, ensuring you're financially prepared. Approaching your reimbursement claim with sensitivity and attention to detail can make the process smoother and more efficient, essentially more successful. It helps take care of your financial well-being, one step at a time.
Frequently Asked Questions
Here are some of the most commonly asked questions related to reimbursement claim settlement.
What is a reimbursement claim in health insurance?
A reimbursement claim in health insurance is when you pay for medical expenses out of your pocket and then request your insurance company to repay you for those expenses.
What documents do I need to file a reimbursement claim?
You'll essentially need documents like medical bills, invoices, prescriptions, and diagnostic reports as proof of your expenses. These documents help the insurance company verify your claim.
How long does it take to get reimbursed?
The processing time varies but generally takes a few weeks. It depends on the insurance company's review process and the completeness of your documentation.
What expenses can be reimbursed?
Eligible expenses include hospitalization, doctor's fees, medicines, and other medical treatments covered by your insurance policy. Always refer to your policy document for a detailed list.
Can I choose any healthcare provider for treatment in a reimbursement claim?
Yes, you have the flexibility to choose any healthcare provider you prefer. You're not limited to network hospitals or doctors.
Is there a waiting period for reimbursement claims?
Some health insurance policies have a waiting period for specific treatments or pre-existing conditions. During this period, those expenses may not be eligible for reimbursement.
Are all reimbursement claims tax-free?
Not necessarily. Some reimbursement claims may be subject to taxation. It depends on the nature of the expense and tax laws in your country.
Can I submit a reimbursement claim for expenses not covered by my policy?
Generally, no. Reimbursement claims are typically for expenses that fall within the scope of your policy. Expenses that are explicitly excluded may not be reimbursed.
How do I check the status of my reimbursement claim?
You can usually check the status through the insurance company's customer portal, or website, or by contacting their customer service.
What if my reimbursement claim is denied?
If your claim is denied, review the denial letter from the insurance company to understand the reason. You may have the option to appeal the decision or seek clarification.
Can I claim reimbursement for expenses incurred abroad?
Some health insurance policies offer international coverage, but it's essential to check your policy's terms and conditions regarding overseas expenses.
Is it possible to expedite the reimbursement process in emergencies?
In emergencies, some insurance companies may offer expedited processing. Contact your insurance provider for guidance on handling urgent situations.
Is a cashless claim better than a reimbursement claim in a health insurance policy?
A cashless claim has its own set of advantages. One of the talking points of the reimbursement claim is that you have the flexibility to avail treatment in a hospital of your choice. That means, in a medical emergency, you need not waste your time in locating a network hospital. So, it all depends on which is the convenient option for you.
How much time does it take to settle my health insurance reimbursement claim?
ACKO may settle your claim within 7 days of the receipt of the claim-related documents. However, the timeframe may differ depending on the complexity of the claim.
Is a health insurance reimbursement claim taxable?
No, the reimbursement received from your health insurance provider (ACKO) is not taxable because it does not account for profit or income for the insured.
Is there any timeframe to apply for a reimbursement claim at ACKO?
Yes, you need to raise the claim within 30 days of the hospitalisation. However, we recommend that you apply for a claim as soon as possible. It allows ACKO to settle the claim quickly.
| Disclaimer: *Except for exclusions like maternity benefits, undisclosed diseases, etc. Please check policy wordings for more details. |
| The plans, services, features, processes, and other details mentioned on this page are subject to availability and changes. Please check the applicable policy wordings before making any insurance-related decisions. Feel free to reach out to us at [email protected] for any queries. |
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