Ultimate Guide to Medi Assist Reimbursement Claim Process

Medi Assist is one of the leading third-party administrators (TPA) providing its services to millions of policyholders of top insurers in the country. Medi Assist is also the TPA for group insurance policyholders from companies such as TCS, IBM etc. In this article, we will explain the reimbursement claim process of Mediassist, including advice on supporting documents required in the claim, how to fill Mediassist claim form and claim submission formalities.

Medi Assist Cashless Claim Process

  • For pre-authorization, present your insurance e-card and valid government ID proof at the hospital.
  • Hospital sends your pre-authorization form to Medi Assist TPA and the TPA will go through the policy terms and conditions.
  • Medi Assist sends approval to the hospital for cashless treatment subject to terms and conditions of the policy.
  • On discharge, the patient pays the deductibles, if any. If there are no deductions, the patient gets discharged without paying anything out of their pocket.

To generate your Medi Assist e-card, click here.

Medi Assist Reimbursement Claim Process

You can opt for reimbursement claim if the hospital is not in the Medi Assist network hospital list.

  • Intimate Medi Assist TPA in advance about the impending claim.
  • Fill the Medi Assist reimbursement claim form and submit your claim online within 7 days from discharge.
  • Send all the necessary documents to Medi Assist TPA within 30 days of discharge.
  • Keep track of your Medi Assist claim status to be able to resolve the query in time.
  • In case of approval, the amount will be reimbursed in your NEFT account.

To get the Medi Assist claim Intimation form, please click here.

Documents Required for Medi Assist Reimbursement Claim

Document requirement in the claim can be broken down into 4 categories. Depending on the nature of your claim, some categories may not apply.

KYC Documents

These documents establish the identity of the patient and the main policyholder and bank transfer detail. Typically four documents are required in every claim:

  • 1. Aadhaar card copy of the patient
  • 2. PAN card copy of the primary or main policyholder/employee. If PAN is not available, substitute with any other govt. ID proof
  • 3. Copy of the Medi Assist card or insurance policy certificate (either of patient or primary policyholder)
  • 4. An original canceled cheque of the primary policyholder’s bank account.

Hospitalization & Treatment Documents

Documents that you received from hospital – such as discharge summary, hospital bill, payment receipts, bill breakup, package breakup etc. need to be attached in the claim. All documents need to be original, on colored/printed letterhead of the hospital. Check for following points:

  • Hospital main bills are generally a summary of expenses. Make sure to ask the hospital to give you a breakup
  • If any surgery package has been added in your bill, ask for the package breakup on hospital’s letterhead or it may be on a plain paper with hospital’s seal
  • Receipts of all payments made to the hospital must be added in the claim. Total of the amount mentioned in receipts should match the final bill amount (after deduction of discounts, if any)

If yours is a pre-hospitalization and/or post-hospitalization claim only, then you do not need to bother giving hospital bills or bill breakups. Only a photocopy of discharge summary is sufficient.

You will only be having a consultation, pharmacy, physiotherapy and lab bills, so just add them in your claim. Make sure to check your eligibility for the duration of pre and post hospitalization. All bills in pre and post hospitalization claim need to be in the original.

Remember to add doctor prescriptions (in original) as supporting evidence for all pre and post hospitalization bills you are submitting. In the absence of the same, Medi Assist will not pay for those expenses.

Investigation Reports

Carefully examine all the lab investigations and scans billed by the hospital and reconcile with the reports you have with you. You need to gather all reports in the original. Original means they need to be on the colored/printed letterhead of hospital or lab. Print on plain paper with hospital/lab seal won’t be accepted by Medi Assist.

If you miss out on any report, Medi Assist may deduct the amount billed for those investigations or it may even raise the query in the claim asking you to furnish those reports. Best thing to do when any report is not available with you is to add a cover-note in your claim and mention the date-wise list of reports which you will not be able to submit as you don’t have them.

If you are filing a pre and post hospitalization claim, make sure you add reports of all investigations for which you are submitting the bills. These also need to be backed by doctor prescription on their letterhead or a lab requisition slip. Most claimants make mistake in this step and lose a lot of money in their claim.

Accident Details, if Applicable

In claims pertaining to accidents, there are additional documentary evidence required such as Medico-legal Certificate (MLC) from the hospital where treatment was taken and Police FIR copy if the accident/dispute was reported to police.

If the accident pertains to self-injury, make sure to add a letter signed by the patient giving elaborate details on how the patient injured himself/herself. It could be a case of self-fall or being hit while playing.

Medi Assist Claim Form

Along with the documents listed above, you need to download the Medi Assist Claim Form for reimbursement. This is equivalent of Part A in IRDA Claim form. Medi Assist does not require Part B of the IRDA claim form.

Download Medi Assist Claim Form

How to Fill Medi Assist Claim Form

There are eight sections in Medi Assist reimbursement claim form (also called as Part A form) identified as Section A-H.

Section A-C

In the form, you have to fill in insurance details of the primary policyholder and the patient in Section A, B, and C. Primary policyholder is the person in whose name the policy has been issued, and in case of corporate employees, the employee is the primary policyholder.

Section D

Next, you need to fill treatment-related details in Section D, like date of admission and discharge, the first date when the disease was detected, nature of treatment – was it for an injury or illness and related details.

Section E-F

Afterward, billing details are captured in Section E and F. All the expenses you incur towards your treatment can be put into 3 segments – Pre Hospitalization (expenses before admission to hospital), Hospitalization (expenses during the time you stayed at the hospital) and Post Hospitalization (expenses incurred after discharge from the hospital).

List your bills in a sequence and based on the segments explained above, calculate your Pre, Post and Hospitalization expenses and fill in the form. If you need to claim specifically the expenses towards ambulance, health-check, daily lump sum hospital cash etc based on your policy terms, you have separate fields where you can enter these claim amounts.

The same information needs to be presented in Section F with a minor difference. All the pharmacy expenses must be taken out of your total bills and filled separately. The remaining amount of Pre, Post and Hospitalization duration must be filled in the fields provided in Section F. Please note that in the form, space is provided only for 10 bill details. If you have more bills that this, you can separately attach a list along with this claim form.

Section G-H

Towards the end, we have Section G where the bank details of primary policyholder are to be entered.

Generally, you can find these details on the cheque leaf issued by your bank. Note that the exact name of the bank account holder as per account details must be mentioned in ‘Cheque / DD payable details’. Lastly, you need to sign the declaration in Section H.

Medi Assist Claim Submission Timeline

While the submission timelines specified in different policy documents vary, it is safe to assume that you get 15-30 days time to submit your claim to Medi Assist after the discharge of the patient. If you fail to do so, Medi Assist can reject your claim. However, if you are delayed because of a justifiable reason, you can submit a letter along with your claim providing justification for delayed submission. If the reason is acceptable to Medi Assist, they will process your claim.

If by any chance you are going to be delayed in your claim submission within this timeline, we suggest that you prepare the claim form and attach whatever claim documents are available with you and submit to Medi Assist before the 30 day period ends after discharge. This way you will be able to meet the deadline. Afterward, Medi Assist will raise a query or additional document request in your claim and you can submit the other documents then. This helps you buy some more time.

Claim Submission Address

If you are a corporate employee, you can submit the claim in your office to the Medi Assist representative who may be visiting your office on a set frequency.

Otherwise, we suggest you could send your claim documents to the following address:

Medi Assist Health TPA, Tower D, 4th Floor, IBC Knowledge Park, 4/1 Bannerghatta Road, Bengaluru, Karnataka 560029

Make sure that you keep safe the receipt of courier or post office slip till your claim gets approved. You must use a courier service where you can track the delivery online. Once you observe that the documents have reached Medi Assist, in a day or two you receive a message from Medi Assist with the claim number and a claim tracking link URL. You can use this link to view your latest claim status.

Frequently Asked Questions

When you claim your expenses from Medi Assist after paying the hospital and treatment bills, it is called as reimbursement claim. In a cashless claim, hospital takes approval from Medi Assist to provide treatment to patient by charging the expenses directly to Medi Assist. Patient only pays for non-admissible charges, copay or any other deductions in cashless. In reimbursement claim, you are required to first make the payment and then send the claim form and other supporting documents to Medi Assist for settlement of your dues.

Financially speaking, it hardly matters. Insurance company will pay as per policy terms and conditions irrespective of whether you go for reimbursement claim or cashless claim. One advantage in cashless is that you get quick approval and you don’t need to block your money for a few weeks.

In cases of planned admissions, claim intimation is an important activity and it should be done within 48 hours prior to admission. If it is an unplanned or emergency admission, then in that case, intimate Medi Assist after the admission. Click here for the intimation link. You can also call the customer care and intimate regarding the claim.

Ideally, claim approval takes 2-3 weeks from the date of submission. Afterwards, Medi Assist sends intimation to insurance company regarding claim approval and amount approved. Insurance company then make a transfer to the account specified in claim documents. While Medi Assist website claims that it takes 7 working days for payment to reach account after claim approval, in our experience, it can take another 2-4 weeks for insurance company to process the payment.

Now this works well when there is no query or additional document request raised in the claim. If Medi Assist asks for additional information or documents, depending on the nature of this requirement, you can expect claim to get delayed by another 4-8 weeks.

In a few claims, Medi Assist needs to check whether there was any non-disclosure of pre-existing diseases, or the claimant may have missed out of providing all the supporting documents. There can be many varieties of queries and it is completely dependent of type of policy, treatment taken and claim documents submitted. Any gap in these can lead to a query, shortfall or additional document request.

This means your claim has now been parked aside and it will only move ahead once you submit proper response to query.

Ideally you must submit your claim to Medi Assist within 15 days from the date of discharge. 15-30 days after discharge date is a reasonable safe period to submit the claim. Beyond this, you can still submit your claim, but you must add a letter providing justification for the delay in claim submission. If your reason for delay is accepted, your claim will be processes.

To give you an example, we had a client who joined her company about a year back just after graduation. Her father was diagnosed with chronic kidney disorder and so he had to undergo dialysis 3 times in a week and our client’s mother had to accompany him for dialysis. Our client was the only bread-winner for the family. Since the dialysis center was not empanelled with Medi Assist, she did not get cashless facility there and she was struggling to keep up at work and manage family priorities. Finally she managed to submit her claim for her father’s dialysis after 3 months from the date his dialysis started. We’re able to justify the delayed and she got her claim amount.

Our suggestion is, whatever anyone tells you, you must always submit your claim whatever time may have elapsed after discharge from hospital. Give adequate justification and keep your fingers crossed.

Now practically speaking, not all are able to submit claim within the deadline because of various personal and professional priorities. The best thing to do is then to submit the claim form and claim documents available with you within 15-20 days from discharge. Atleast you have met the deadline. Medi Assist will then raise query for missing documents. Those you can arrange and submit.

Visit www.medibuddy.in/claim and enter your Medi Assist ID and date of admission in the form to track your claim.

Yes, you can claim the unclaimed amount from a second insurance policy after cashless claim in Medi Assist exhausts your sum insured. You need to first write to Medi Assist customer care on info@mediassistindia.com requesting for (1) Settlement letter of your cashless claim (2) Attested copies of the claim documents, including discharge summary, hospital bill, bill breakup, payment receipts, lab and other investigation reports.

Make sure that Medi Assist sends these as hard copies to your address. These documents you will need to submit to your second insurance company.

Visit www.medibuddy.in/ecard to download your Medi Assist E-card. For this, you need the Medi Assist ID, Claim number or employee number of main policyholder.

But if you only have your policy number from National Insurance, New India, Oriental or United India insurance, then you will first need to contact Medi Assist customer care and ask them for the associated Medi Assist ID the insured persons and then generate the ecard from the link.

Medi Assist has a one page reimbursement claim form which is same as the IRDA Claim Form part A. Medi Assist does not ask for part B of claim form in claims.

Filling the claim form is the most important thing. Every claimant needs to fill a claim form. Claimants are required to fill these standard forms but every claimant’s knowledge significantly varies and not everyone has all the information at their disposal to fill these forms. If you make mistakes in the form, you run the risk of delay payments or deductions or in worst cases, claim rejection.

You can also get an expert to prepare your claim or consult an Insurance expert for any query related to your claim.

We're Here to Help

Get 360 degree claim assistance from our in-house claim experts.