Step-by-Step Guide to Fill Health Insurance Reimbursement Form

The best part about getting health insurance for you and your loved ones is that you never have to worry about bearing the financial burden of healthcare costs in case of emergencies. And to make the process even more smooth for you is the exclusive advantage of cashless hospitalization provided by most insurers. This facility can be availed at any of the network hospitals near you, which is provided by your insurance company.

However, it cannot be ignored that medical emergencies can come in uncalled for anytime, anywhere. What if you don’t have access to one of your insurer’s network hospitals at that time? Treatment cannot wait and so you’d need to avail whatever best you have at your disposal at the time. Your insurance company would, however, reimburse the costs borne by you at a non-network hospital up to the limit covered by your insurance plan.

For this, your insurer would ask you to simply fill out a health insurance reimbursement form, a simple document with all the details of your treatment and the costs borne therewith. Read on to know more about this form and how exactly to fill it out in case you ever have to.

Health Insurance Claim Reimbursement Form

As stated above, your insurance company may require you to fill out a reimbursement form in case you did not avail of cashless hospitalization at one of the network hospitals of the insurer. This form is generally handed over to the patient after they have been discharged from the hospital. The patient must submit this claim reimbursement form, along with the other relevant documents, to their insurance company within 15 days of being recharged, after which the company may not entertain your reimbursement claim request.

A claim reimbursement form contains two parts, both of which need to be duly filled:

• Part A: This is meant for the patient, or the policyholder, in this case. They are required to fill in their complete details – personal details and contact information – along with the details of their health insurance policy (policy number, date of expiry, and the like). Besides this, you would also need to provide relevant details about your hospitalization – the treatment taken, its duration, and the total cost borne.
• Part B: This part of the reimbursement form is meant only for the staff of the particular hospital where the patient had been admitted for treatment. They would fill out all the information pertaining to the hospitalization of the patient, the reason for which they had been admitted (health condition) and the insurance claim.

Steps to Fill Out a Health Insurance Reimbursement Form

Here’s how you can complete your claim reimbursement form easily and without making any mistakes:

1. Fill in all details of the primary insured under the plan. This is important when the health insurance policy covers more than one person, such as a Family Health Plan where you may be the primary insured and your dependent parents may be listed as the beneficiaries. Note that the complete details of the primary insured can be found in your health insurance policy documents received from the insurer at the time of purchasing the plan.

You would need to submit the relevant details such as the policy number, your name and contact details.

1. Fill out details pertaining to the insurance history, if any, of the insured patient. Your insurance company would need to know whether or not the patient filing the claim is covered by any other health insurance plan. In case he/she is, then they must submit all details regarding that mediclaim policy under the relevant section of the reimbursement form.

This would include filling out the insurance company’s name under which the patient is covered, the policy number of that health insurance plan, and the total sum insured under that plan. Besides, you may also need to furnish details about prior hospitalization history, if any, and any prior record of insurance coverage for the hospitalization.

1. Fill out details of the insured patient. Next, you would need to disburse all information pertaining to the patient who had been hospitalized and who is also covered under the health insurance plan. This section would cover the personal details of the insured patient for whom the claim is being filed with the insurer.

You would need to fill out the name of the insured, their relationship with the primary insured person under the policy, their contact details, and their occupation.

1. Now, you’d need to fill out details regarding the hospitalization of the insured patient. This would include entering the name of the hospital, why the patient had to be hospitalized, the type of room where the patient stayed during the duration of hospitalization, and the date of admission and discharge of the patient. In case of a legal case, a copy of the FIR must also be attached along with the above details.
2. Fill out the details of the total amount being claimed for insurance coverage. This section of the health insurance reimbursement form requires you to fill out the claim details. Before filling this out, it’d be a good idea to arrange all your hospital bills in order of date so it’d be easy for you to enter the required relevant details.

You’d be required to collect all original reports for the treatment from the hospital, right from the date of admission until the date of filing the claim. You’d also need all original receipts of hospital bills for all tests conducted as well as pharmacy bills. In case you have any receipts of lump sum cash benefit received from the insurer, attach those as well along with the other documents.

The claim amount would need to be computed based on the pre-hospitalization costs incurred, the expenses borne during the hospitalization of the insured patient, the post-hospitalization costs incurred for the patient, as well as any other costs involving use of ambulance or any health check-ups performed (if applicable).

1. The next section of the reimbursement form would require you to provide an explanation for all the bills that you attach with your claim. You’d be required to enclose and furnish complete details of the main hospital bill stating the total amount, the complete pre-hospitalization bills and the total amount stated therein, the complete bills of post-hospitalization treatment along with the sum total incurred therein, and the total number of pharmacy bills.
2. The last step in filling the health insurance claim reimbursement form is to provide the bank details of the primary insured, in whose name and bank account the claim amount would be transferred by the insurer. Make sure to enter accurate details under this section.

The insurer would require you to provide your bank name and branch, bank account number, IFSC code, PAN details, and Cheque/DD details.

Make sure to look through the entire form again once you have completed filling it. At the end, the insured would need to provide their signature and mention the date of filing the claim. Also ensure that Part-B of the form (as described in the above section) has been duly filled in by the hospital.