What documents are needed to file a health insurance reimbursement claim?

A group health insurance reimbursement claim requires nine core documents at minimum: a duly filled claim form, the original discharge summary, an itemised hospital bill, payment receipts, all diagnostic and investigation reports, prescriptions and pharmacy invoices, the treating doctor's certificate, the insured's photo ID and cancelled cheque, and the policy document or e-card. Insurers have 30 days from receipt of the last document to settle or reject the claim under the IRDAI Master Circular on Health Insurance Business dated 29 May 2024 (ref IRDAI/HLT/CIR/MISC/77/05/2024). Delays beyond 30 days attract interest at 2% above the prevailing RBI bank rate.

What is a reimbursement claim in group health insurance?

A reimbursement claim is a post-treatment settlement where the employee pays the hospital directly and files the bills with the insurer for repayment. It applies when the hospital is outside the cashless network, when cashless pre-authorisation is denied, or when the employee elects to pay upfront. The reimbursement route accepts the same treatments and sum-insured limits as the cashless route; the difference is only in the timing of the payment.

What documents does IRDAI require for a reimbursement claim?

The insurer needs a specific document set to verify the treatment and confirm the amount is covered by the policy. The nine items below are the industry-standard checklist for a group health claim in India:

• Duly filled and signed claim form (Part A by the insured, Part B by the treating hospital)
• Original discharge summary with diagnosis, treatment details, and duration of stay
• Itemised final hospital bill with break-up of room rent, medicines, doctor fees, and procedure charges
• Original payment receipts against the hospital bill
• All diagnostic and investigation reports (lab, imaging, pathology)
• Prescription slips and pharmacy invoices for medicines purchased outside the hospital
• Treating doctor's certificate confirming diagnosis and line of treatment
• Insured's photo ID (Aadhaar, PAN, or passport) and cancelled cheque for NEFT transfer
• Policy document or e-card, along with the employee's HR verification for group coverage

Insurers accept scanned copies through their mobile app or portal, though most retain the right to request originals within 30 days if flagged for verification.

What extra documents apply to specific treatments?

Certain treatments require additional supporting documents beyond the standard checklist. Maternity claims need the birth certificate of the newborn if a maternity benefit is being invoked. Accident-related claims require the FIR copy and the Medico-Legal Case (MLC) certificate from the hospital. Cancer treatment claims need the biopsy or histopathology report along with the oncologist's treatment protocol. Cataract or joint replacement claims require the implant sticker or purchase invoice for the intraocular lens or prosthesis. Missing any of these documents will cause the insurer to raise a query, and the 30-day settlement clock restarts from the date of the completed submission.

What is the submission deadline for a reimbursement claim?

Most group policies require intimation within 24 to 48 hours of hospitalisation and document submission within 30 days of hospital discharge. HDFC ERGO and ICICI Lombard typically allow 15 to 30 days for intimation and a further 30 days for document submission. Star Health and Bajaj General set similar windows. Late submission does not automatically void the claim under the IRDAI Master Circular; the insurer must consider the reason and apply proportionate discretion. The safer practice is to intimate the insurer within 24 hours of hospitalisation and submit documents within 15 days of discharge.

What happens if the submission is incomplete?

An incomplete submission triggers a query letter from the insurer specifying the missing documents, and the 30-day settlement clock pauses until the insurer receives the last required document. Repeated queries slow settlement without voiding the claim. If the insurer rejects the claim after the full document set is submitted, the rejection letter must state the specific policy clause invoked. The insured then has 30 days to escalate to the insurer's grievance officer, followed by IRDAI's Bima Bharosa portal (bimabharosa.irdai.gov.in) and the Insurance Ombudsman if unresolved. Ombudsman awards up to ₹50 lakh are binding on the insurer and must be complied with within 30 days.

How Plum handles reimbursement claims for group health

Plum sits between the insured employee and the insurer as a licensed broker (IRDAI Registration No. 897) and manages the reimbursement submission end to end. Employees upload documents through the Plum app; the claims team validates the checklist against the specific insurer's requirements (ICICI Lombard, HDFC ERGO, Bajaj General Insurance, Star Health, Niva Bupa, or Aditya Birla Health Insurance) before submission. The median pre-authorisation TAT across the book is 45 minutes and claims NPS is 79. For companies with 7 or more employees, Plum's group cover extends to reimbursement claims with the 30-day IRDAI settlement window and interest protection for late payments.

Frequently asked questions

How long does an insurer have to settle a reimbursement claim?

30 days from receipt of the last necessary document under the IRDAI Master Circular dated 29 May 2024. Delays beyond 30 days attract interest at 2% above the RBI bank rate, currently around 8.5% per annum.

Can I submit reimbursement documents online?

Yes. Most insurers and brokers accept scanned or photographed documents through their mobile app or web portal. Originals may be requested only if the claim is selected for verification.

What if the hospital did not provide an itemised bill?

Ask the hospital to reissue the bill with a break-up of room rent, procedure charges, doctor fees, medicines, and consumables. A consolidated bill without itemisation is a common rejection trigger.

Are pre-hospitalisation and post-hospitalisation expenses reimbursable?

Yes, subject to the policy definition. Most group policies cover 30 days of pre-hospitalisation and 60 days of post-hospitalisation expenses linked to the same treatment.

What if the treatment is at a non-network hospital?

Reimbursement is available at any IRDAI-recognised hospital with in-patient facilities, at least 10 beds, and 24-hour medical supervision. The IRDAI Cashless Everywhere circular dated 23 January 2024 extends cashless access even at non-network hospitals for emergencies, though reimbursement remains available if cashless is not activated.

Can a rejected claim be reopened?

Yes. File a written representation to the insurer's grievance officer within 30 days of the rejection letter, citing the policy clause and any new evidence. Escalation paths include Bima Bharosa (IRDAI's grievance portal) and the Insurance Ombudsman (award limit ₹50 lakh).