Health Insurance Cashless and Reimbursement Claims

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Health insurance provides us with financial security and access to medical services for individuals and families. By offering coverage for various healthcare expenses such as hospitalisation, medical treatments, and prescription medications, it eliminates the burden of hefty medical bills.

The health insurance claim process includes a few steps that policyholders must complete to seek reimbursement or get direct payment for covered medical services. Understanding the claim process is vital, as it ensures timely access to funds and helps policyholders navigate the complexities of submitting the necessary documentation and adhering to specific guidelines.

There are primarily two types of health insurance claims, cashless insurance claims, and reimbursement claims. Let’s understand these in more detail.

What is Cashless Claim in Health Insurance?

As the name says, a cashless health insurance claim fundamentally means that policyholders can opt for cashless treatment at their respective insurance provider’s network hospitals. Further, the medical bill gets settled between the insurance provider and the hospital.

By availing of the cashless feature, individuals don’t have to worry about accessing immediate cash during an emergency situation as the payment is taken care of by the concerned insurance company. Taking inflation and rising medical expenses into account, a cashless health insurance claim is a privilege, considering how challenging it can be to meet medical costs efficiently.

What is a Reimbursement Claim in Health Insurance?

Contrary to cashless health insurance claims, those who choose reimbursement health insurance claims have to pay their medical bills by themselves. Later on, upon submitting medical bills to the respective insurance provider, policyholders get their bill amount reimbursed.

With a reimbursement claim, health insurance policyholders have the flexibility to choose any hospital outside their network. It is not mandatory for insured individuals to access medical benefits/ treatment from their providers’ network hospitals.

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Distinction Between Cashless and Reimbursement Claim

The following table lists all the key differences between cashless and reimbursement health insurance claims -

Cashless Health Insurance Claim Reimbursement Health Insurance Claim
To avail of a cashless claim, you must visit a network hospital of your insurance provider. For reimbursement claims, you can usually visit any hospital even if it is not included in your insurer’s network hospital.
In a cashless claim, you don’t have to pay upfront cash for your medical bills. If you avail of a reimbursement claim, you would be required to pay the amount mentioned in the bill and submit it to your provider for reimbursement.
When it comes to making a claim with your insurance plan, you must inform your provider in advance and submit the claim so that the provider directly settles the bill with the hospital. In a reimbursement claim process, you must file your claim after the treatment and submit hospital bills for reimbursement.
Cashless claim processes are usually quick. Reimbursement claim processes generally take more time than cashless claims.

How to Make a Cashless Insurance Claim?

While the exact process will depend on your chosen provider, you can check out the commonly-followed process for claiming cashless health insurance -

  • Go through the list of network hospitals mentioned in your policy document.
  • Select your preferred hospital and get in touch with its insurance help desk.
  • Provide your policy details and fill in the pre-authorisation form.
  • Upon submitting the form and other details, your claim process will be initiated and hospital bills will be settled accordingly.

How Does a Reimbursement Health Insurance Claim Work?

To make a reimbursement claim, follow these steps -

  • Notify your provider regarding the medical treatment that you want to avail of.
  • After the treatment from your desired hospital, settle the medical bills and collect other documents such as prescriptions, medical reports, and so on.
  • Download the health insurance claim form from your provider’s website and fill it out correctly.
  • Submit the form and other required documents to your provider as prompted.
  • One of the representatives will evaluate your form and reimburse your bill amount.

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