When you or your loved one gets hospitalized, the last thing you want to deal with is a pile of paperwork. That’s where understanding how reimbursement claims in Mediclaim work becomes so important. Whether you’re dealing with a non-network hospital or your cashless claim was denied, this guide breaks everything down—step by step.
Introduction to Mediclaim Reimbursement
Mediclaim is a type of health insurance that helps you cover medical expenses. Most people know about cashless claims, where the hospital settles bills directly with the insurer. But in many situations, you might need to pay upfront and then get reimbursed later.
This is known as a reimbursement claim. Instead of the insurance company paying the hospital directly, you pay first, collect all the documents, and then apply to get your money back.
When Can You File a Reimbursement Claim?
You’ll usually need to go for reimbursement when:
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You get treated at a non-network hospital (a hospital not tied up with your insurer).
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The cashless facility is not available in an emergency.
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The TPA (Third Party Administrator) or insurance company rejects the cashless request.
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The treatment is not pre-authorized (if required).
To be eligible, the treatment must be covered under your policy terms. Always check your policy booklet or the insurer’s website.
Step-by-Step Process to File a Reimbursement Claim
Here’s how to go about it:
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Inform the Insurer or TPA as soon as you're admitted (some policies have a 24-hour deadline).
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Pay the hospital bills from your own pocket.
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Collect all original documents: bills, reports, discharge summary, prescriptions, etc.
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Fill out the reimbursement claim form (downloadable from your insurer's site).
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Submit the form and documents to your insurer or TPA.
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Follow up regularly until your claim is processed.
Don’t forget to keep copies of everything you submit.
List of Documents Required
Submitting the right documents is key. Here’s what you’ll typically need:
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Duly filled claim form (signed by you and the hospital)
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Original hospital bill and payment receipt
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Discharge summary or final hospital report
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Prescriptions and medicine bills
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Diagnostic test reports (X-rays, blood tests, etc.)
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Doctor’s consultation notes
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Your ID proof
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Your bank account details (for refund)
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Policy copy or health card (optional but helpful)
Some insurers might ask for additional paperwork, so check their checklist.
Common Reasons for Claim Rejection
Claims can get rejected if:
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You miss the submission deadline (usually 7–30 days after discharge).
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You submit photocopies instead of original documents.
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The treatment is not covered under your policy.
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You leave out important paperwork.
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The insurer suspects false information or overcharging.
Double-check every form and bill before submission to avoid rework.
Timelines and Turnaround for Claim Settlement
Generally, insurers take about 7 to 30 days to process reimbursement claims. According to IRDAI (Insurance Regulatory and Development Authority of India) rules:
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Insurers must settle claims within 30 days of receiving all documents.
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If they need more investigation, it must be completed within 45 days.
You can track your claim status online or by calling customer support.
Tips to Ensure a Smooth Reimbursement Process
Want to get your claim approved faster? Here are some tips:
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Inform the insurer as soon as possible after admission.
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Always read your policy terms to know what’s covered.
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Keep all original bills and reports safe and organized.
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Use a document checklist when submitting the claim.
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Stay in touch with your TPA or insurance agent for updates.
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Take note of claim reference numbers.
Being organized can make a huge difference.
Difference Between TPA and Insurance Company
A TPA or Third Party Administrator acts like a middleman between you and your insurer. Their job is to:
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Process your claim documents
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Help with approvals and verification
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Provide customer service
But the insurance company is the one that actually pays the claim. Some insurers handle claims in-house, without TPAs.
Digital Claims and Online Submissions
Good news—many insurers now allow you to upload documents online or via their mobile apps.
Benefits of digital claim submission:
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Faster processing
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Track status in real-time
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Less paperwork
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Email alerts and SMS updates
Just make sure to scan and upload clear copies and still keep your originals till the claim is fully settled.
FAQs on Mediclaim Reimbursement
Q: Can I claim reimbursement for OPD bills?
A: Usually not, unless your policy has OPD cover.
Q: Is pre-authorization needed for reimbursement?
A: No, it’s mainly needed for cashless claims. But informing the insurer early is always good.
Q: What if I lose my original documents?
A: It can delay or even cancel your claim. Always make photocopies and take photos before submission.
Conclusion
Mediclaim reimbursement might feel like a lot of paperwork, but with the right steps and attention to detail, it’s absolutely manageable. The key is to stay informed, follow your insurer’s process closely, and keep every bill and report in place. That way, you can focus more on recovery and less on the hassle.
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