What is the Claim Process in a Group Health Insurance Policy?

A simple claims settlement process is one of the important features of Group Health Insurance Policy and it is important for employers to understand the Claims Process under a Group Health Insurance Policy.

A Group Health Insurance Claim is a request submitted by the Insured Employee under the Group Health Insurance Policy to claim reimbursement for the hospitalisation expenses incurred by the employee during the Policy Period. 

It is important to understand the Claims Procedure under a Group Health Insurance Policy and this article will explain the different types of claims settlement processes under a Group Health Insurance Policy and the steps involved in making the claim under each type of process under a Group Health Insurance Policy.

What are the types of Claims under a Group Health Insurance Policy?

There are two types of ways in which an Insured Employee can avail Claim Settlement under a Group Health Insurance Policy.

Cashless Claims Settlement 

The Insured Employee can raise a cashless claim settlement request under a Group Health Insurance Policy when he avails treatment at one of the network hospitals. In a Cashless Claim Settlement Process, the Insured Employee just needs to give the Group Health Insurance E-Card to the hospital at the time of hospitalisation, and the entire medical expense will be settled directly between the Group Health Insurance Provider and the Hospital.

Most TPAs usually approve cashless claims within 4 hours from the time of admission at the network hospital. The advantage of cashless claim settlement is that the employee does not need pay any amount from his own pocket since the claim is directly settled by the Group Health Insurance Company with the Hospital.

Reimbursement Claims Settlement 

If Insured Employee avails treatment at a non-network hospital, then he will not be able to avail cashless claim settlement and instead he will have to opt for a reimbursement claim settlement process.

In a Reimbursement Claims Settlement Process, the Insured Employee will have to pay for the hospitalisation and treatment expenses out of his own pocket and then raise a claim for reimbursement separately with the Group Health Insurance Company by submitting the requisite documents such as medical bills, hospital discharge summary and the reimbursement claim form.

What is the Cashless Claim Settlement Process under a Group Health Insurance Policy?

The claims process for availing cashless claim settlement under a Group Health Insurance Policy is listed below:

  1. Locate the nearest network hospital covered by the Group Health Insurance Policy to avail treatment
  2. Inform the Group Health Insurer about the hospitalization before 3-4 days in case of a planned hospitalization and within 4-5 hours in case of an emergency
  3. Show the Health Card issued by the TPA to the insurance desk at the hospital
  4. Fill the pre-authorization Claim Form provided by the hospital
  5. The Hospital sends the pre-authorization Claim Form to the Group Health Insurance Provider for claim settlement
  6. The Group Health Insurance Company will inspect the details and inform the insured about the approval or rejection of the claim
  7. Once the claim gets approved, the hospital sends the expenses and receipts to the Group Health Insurer and the hospital gets reimbursed for the treatment expenses directly by the Group Health Insurance Company.

What is Reimbursement Claim Settlement Process under a Group Health Insurance Policy?

The claims process for availing cashless claim settlement under a Group Health Insurance Policy is listed below:

  1. Inform the Group Health Insurer within 24 hours of admission to the hospital. The TPA will provide the employee a Claim Number after the claim is raised so that the Group Health Claim Status can be tracked
  2. Make the payment to the hospital for the medical expenses incurred and keep original copies of all the invoices
  3. Submit the required documents to the Group Health Insurance Provider
  4. The Group Health Insurance Company will verify the claim details, ask for additional documents if required and will approve or reject the claim
  5. The approved claim amount gets credited directly to the bank account of the Insured

What are the documents Required for a Reimbursement Claim under a Group Health Insurance Policy?

The Insured needs to submit the following documents to the Group Health Insurance Company to avail Reimbursement Claim Settlement under the Policy:

  1. ID Proof, GMC Policy Health Card and Address Proof
  2. Duly Filled and Signed Claim Form
  3. Pathology Reports
  4. Medicine Prescriptions and Pharmacy Bills
  5. Pre and Post-Hospitalisation Bills
  6. Hospital Bills
  7. Discharge Summary

Download Group Health Insurance Claim Forms

New India Assurance Company New India Assurance Group Health Insurance Claim Form
The Oriental Insurance Company Oriental Insurance Group Health Insurance Claim Form
ICICI Lombard General Insurance Company ICICI Lombard Group Health Insurance Claim Form
HDFC Ergo General Insurance Company HDFC Ergo Group Health Insurance Claim Form
SBI General Insurance Company SBI Group Health Insurance Claim Form
Bajaj Allianz General Insurance Company Bajaj Allianz Group Health Insurance Claim Form

What are the important points to remember while filing a Claim under a Group Health Insurance Policy?

There are various terms and conditions associated with your Group Health Insurance Policy which you must be aware before raising a claim under the Policy:

Pre-Existing Disease Cover in Group Health Insurance Policy 

One of the important features of a Group Health Insurance Policy is coverage for Pre-Existing Diseases. Though most Group Health Insurance Policies cover Pre-Existing Diseases from Day 1 without any Waiting Period, it might be the case that your Group Health Insurance Policy might in fact have a Waiting Period. It is important to read the Group Health Insurance Policy Certificate to know the Group Health Insurance Coverage provided by your Policy.

Co-Payment Clause under a Group Health Insurance Policy

Co-Payment clause in a Group Health Insurance Policy indicates that the payment is shared between the Insured and the Group Health Insurance Policy. Co-payment usually varies from 10-30% of the admissible claim amount and denotes the percentage of the medical expenses to be paid by the insured. If a GMC Policy has a 30% Co-Payment Clause, it means that 30% of the admissible Claim Amount has to be borne by the Insured out of his own pocket.

Room Rent Limits in a Group Health Insurance Policy

Room Rent Limit in a Group Health Insurance Policy denotes the percentage of the Claim Amount that the Group Health Insurance Provider will reimburse per day towards room rent charges. The remaining amount needs to be borne by the insured.

For example, if a Group Health Insurance Policy has a Room Rent Capping of 1% of Sum Insured for a Policy with a Sum Insured of Rs2 lakhs, it means that the GMC Policy will only pay Rs2,000 towards room rent. The additional amount will have to be borne by the Insured out of his own pocket.

Be aware of these various clauses in your Group Health Insurance before raising a claim with your Group Health Insurance Provider.

How to Select the Right Group Health Insurance Policy for Employees?

It is very important to select the right Group Mediclaim Insurance Policy for Employees which takes care of their needs. For this purpose, it is important to compare the Group Health Insurance Coverages provided by various Group Health Insurance Companies.

Qian Insurance Broking is a licensed Group Health Insurance Broker. We have tie-ups with Top Group Health Insurance Companies in India and our team will assist you with the best Group health Insurance Policy Quotes and also help the employees with the entire claims process.

We specialise in Group Health Insurance Policy for Small Business and our dedicated team will assist you in compare group health plans for small business. If you wish to purchase the best Group Health Insurance Policy for employees, you can also email us at insurance@qian.co.in or call us at 022-22044989. We would be glad to assist you.

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