Reporting a claim: health insurance step by step

When you use medical care and pay for it out of your own pocket, you can often get your money back from your insurance company. However, it is crucial to follow the correct process: damage report and submit documents confirming the validity of the claim. This handbook shows you how to do it quickly and without stress, regardless of whether your health insurance operates on a cashless basis (assistance, network of facilities) or on a reimbursement basis (reimbursement of costs after treatment).

In practice, most problems arise from missing invoices, illegible medical documents, or overly general descriptions of the incident. In the following steps, we advise you on what to prepare, how to describe the incident, where to send the application, and what to do if the insurer asks for additional information or issues a negative decision.

Before submitting the form, please take a few minutes to verify it., whether the benefit in question is covered at all. In the General Terms and Conditions of Insurance (GTC), you can check the limits, deductibles, and reimbursement conditions. Some policies reimburse costs up to a specified amount per visit, examination, or within a quarterly limit. Sometimes, a deductible applies, e.g., 70–80% of the costs are reimbursed, and the insured pays the rest.

If you need basic context about protection rules, it can be helpful to discuss limits and scope of benefits. This makes it easier to assess whether the application is likely to be approved.

There are two main models of health insurance policies. In the cashless model, you contact the assistance center, which directs you to a facility and settles the bill directly. In the reimbursement model, you first pay for the service and then submit a claim for reimbursement based on receipts and medical documentation.

If you have suddenly fallen ill or had an accident and need to arrange treatment quickly, take a look at the guide on this topic., how to get medical help in practice.

In most cases, the insurer will request two sets of information: description of the incident and complete medical and cost documentation. The general terms and conditions often include a provision stating that after reporting a claim, you must submit a completed form and treatment documentation electronically: diagnosis, treatment plan, test results, and other information about your health. Receipts or invoices for services are also standard for reimbursement.

The clearer and more complete the documents are, the fewer requests for additional information there will be. In practice, this shortens the time needed to process the case.

When reimbursing, the insurer usually expects a bill or invoice showing: the facility's details, the insured person's details, the date of service, the scope of services provided, and the amount to be paid. If the document lacks patient details or the name of the service is too general, ask the registration desk for a correction or additional certificate. It's a small thing that often determines whether the settlement goes smoothly.

If you are just planning to purchase protection and want to know how to choose products, read also, what to look for in health insurance.

The process is similar for most insurers: first, you register your claim, then you send the documents and wait for a decision. Some companies have an online form, while others also accept claims by phone. Once your claim has been accepted, you will often receive confirmation by email or text message, and if anything is missing, the insurer will ask you to send additional documents.

The following sequence works in most cases involving reimbursement of medical expenses from health insurance and minimizes the risk of the application being „suspended.”.

Make scans or good photos of all documents: information cards from the emergency room/admissions room, test results, recommendations, prescriptions, and invoices. If the treatment lasted several weeks, collect documents „in sequence” from the entire process. The general terms and conditions of insurance sometimes explicitly state that the insurer may expect documentation from the entire treatment and rehabilitation process, and not just a single bill.

The description of the event should be specific. Provide the date, place, symptoms or circumstances of the accident, and what services were performed. The insurer may verify the documents and ask for clarification, so avoid generalities such as „abdominal pain.” A better description would be: „sudden abdominal pain, visit to the emergency room, abdominal ultrasound, medication prescribed.”.

If you want to formally prepare for the procedures, see also the section application documents and procedures on our website.

It is safest to send documents electronically (customer portal, form, or email) and keep proof of delivery. The general terms and conditions often require that notifications and statements be submitted for evidentiary purposes in writing, in document form (e.g., email), or electronically. This way, if there are any doubts about the deadlines, you have a clear record.

After registering the case, the insurer confirms receipt of the claim and indicates the further course of action. If the documents are incomplete, you will be asked to send the missing items. This is standard procedure, not „bad news.” Respond quickly, send high-quality scans, and always include the claim number in the subject line of your message.

If the decision is negative, the insurer should state the reason for the refusal. You then have the right to lodge a complaint/appeal, attaching your justification and evidence. In many procedures, complaints are considered within 30 days, and in complex cases within 60 days. If the dispute continues, you can also seek the help of the Financial Ombudsman.