Confused About Medical Claims? Understanding Insurance vs. Reimbursement for Family Expenses

I have a doubt about the medical claim: Is medical insurance different from Medical Reimbursement? For example, I incurred an expenditure of 50000/- for my parents. Can I claim this amount from my company, or do I have to claim it from the insurance company? The company reimburses only 15000/- for the year. Please suggest. Regards, Hari

Dear Hari,

Medical Reimbursement is different from Medical Insurance. Medical insurance is what your company obtains from an insurance company, and you are allocated a specific medical limit that you can use throughout the year. Medical reimbursement occurs when you have a medical claim for treatment received from a hospital not on your insurance company's panel. In this case, you submit the medical claim, and the insurance company reimburses you an amount equivalent to your expenses.

If you visit a hospital within the insurance company's panel, you will not have to spend anything, as the insurance company will directly pay the hospital for your treatment.

Best of luck.

Regards,
Asma Bano

Hi Asman Bano,

For example, my father underwent an operation, and I incurred ₹60,000 for his treatment. Can I claim ₹60,000 plus ₹15,000 as reimbursement expenses? Please advise.

Regards,
Harinath A

No, you didn't understand my point. I said there is a specific medical limit provided to you. If this limit in your company is just 15,000/-, that is a very minimal amount for medical expenses. You will only be reimbursed 15,000/- by the company, and the remaining amount will have to be borne by you.

For Example: I am insured by an insurance company, and my insurance limit is 2.5K per year, with a room limit of 1500k. In the case of a panel hospital, I will not be reimbursed any expenses; all costs, like 60,000 as you mentioned, will be reimbursed to the hospital. In the case of a non-panel hospital, all these expenses will be reimbursed to you, but only up to 60,000/- from the 2.50k. It is not a total of 2.5k plus 60,000; it is 250,000 minus 60,000.

Best Regards

Dear Hari,

Most of the companies provide medical insurance facilities to their employees. It depends on the company's agreement with the insurance company regarding the limit of the sum assured for different employees since all employees fall under different grades within the company. The higher the grade, the higher the sum assured limit (please refer to the company policy).

Therefore, if you incur Rs 60,000/- for your father, please check what your reimbursement limit is. Submit a claim form along with all the necessary supporting documents to HR (for supporting documents, contact your HR). Please note that there may be expenses not covered under the policy, which would not be reimbursed.

If your limit is Rs 15,000/- (which is a very low and unexpected limit), you may only receive reimbursement for that specific amount. For better understanding, reach out to your HR.

Best Regards,
Haider Abbas
Email: haider_abbas@mail2indian.com

Hi,

The term medical reimbursement and medical insurance have two different meanings. Medical reimbursement can be part of your salary negotiations. It will be paid by your organization. As per the IT act, Rs. 15,000 per year is allowed as tax-free medical reimbursement, but it depends on your organization's policy.

Secondly, medical insurance is a welfare measure provided by your organization. Generally, this facility is provided to those employees who are not covered by ESIC. In this organization, contact any insurance agency to decide on the premium amount. At that time, management also decides whether your immediate family (i.e., spouse and children) will be covered, depending on management policy. A sum assured for expenses is provided for each individual employee and their family. When you or your family member is hospitalized due to illness, either cashless benefits will be provided by the hospital, or you have to pay the bill and submit it to your organization for reimbursement, limited to your sum assured. If you have a sum assured of Rs. 20,000, insurance will check the claim papers, and after verification, if there are any deductions on their part, they will send a check to your organization, which will then reimburse you.

Medical reimbursement facilities will also be provided to those employees whose names are in the mediclaim; this will depend on your management's decision.

Regards,

Vinay

9850062122

Hi Abbas,

Can I claim the medical insurance for cosmetic surgery or should we claim medical insurance only if we have some serious health-related problems.

Thank you.

Hi,

My organization provides me with family coverage of Rs. 1 lakh, which includes pregnancy coverage as well (Reliance Mediclaim). Recently, my wife experienced a pregnancy-related complication and had to be briefly hospitalized. The total bill for this came to approximately Rs. 9,000.

I am unsure whether I should claim this amount via mediclaim or if it is reimbursable by my organization under any law. I have been informed that one should not claim amounts under Rs. 15,000. Is this true?

I urgently need assistance as I need to submit my paperwork for processing. Thank you for your help.