Application for Health Insurance Reimbursement – Cover Letter to Insurance Company Requesting Reimbursement

The __________ (Concerned Authority),
________________ (Insurance Company Name),
________________ (Address)

Date: __/__/____ (Date)

Subject: Requesting reimbursement of medical

Respected Sir/Madam,

I would like to state that I am __________ (Name) a permanent resident of ______________ (Address) and I do carry a ________________ (Policy Name – If any) policy issued by your company having policy number _________ (Policy Number) in the name of ____________ (policy golder name).

I would state that on __________ (Date), _____________ (Patient’s Name) got admitted in ______________ (Hospital Name) and was admitted in ____________ (Room Type – Executive/ Simple/ Any Other) room. As per requirement I had already ___________ (intimated / submitted Claim approval request/pre approval authorization)  on _________ (Date) with reference number ____________ (Reference Number).

I request you to kindly reimburse a sum of Rs. ____________ (Amount) in my bank account as cashless service was not available at the hospital due to which I had to pay for the bill.

The following are the details of the patient:
Name: _______________
Gender: _______________
Address: _______________

I am hereby attaching ____________ (Medical Card/ ID Proof/ Address Proof/ Bill/ Form Attested by Hospital – Any other document if applicable).

Respected, as I had to pay for the bill, therefore, I request you to kindly reimburse the amount in my account for the bill paid. I shall be thankful.

Thanking you,
______________ (Signature)
______________ (Name),
______________ (Contact Number)

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