What Is The Claim Process In A Group Health Insurance Policy? 

A group health insurance policy, ultimately, is just another health insurance plan with different intricacies. The group medical insurance policy offers financial coverage and benefits for medical emergencies for multiple people under one plan. 

Comprehending nuances such as group health insurance premiums, proportions, coverage and claims is paramount. Another aspect of a group policy is the claim settlement procedure and its different types. 

In this blog, we delve into the corporate health insurance claim process and its types.

Types of Claim Process in a Group Medical Policy 

In employee medical insurance, insurance companies offer you two types of claim settlement procedures. Each method has its own set of procedures, benefits and document requirements. 

Cashless Claim Settlement

Cashless claim settlement in a GHI policy refers to the process where the insurance company directly settles the medical bills with the hospital. This means that the policyholder does not have to make excessive out-of-pocket payments and wait for the insurance company to reimburse them. 

Insurance companies used to have a list of network hospitals that offered this service to their policyholders. Although, according to IRDAI’s changed rules and regulations, policyholders from any insurer can enjoy the service at any authorised hospital.

Reimbursement Claim Settlement 

Reimbursement refers to a process where the policyholder first covers the medical expenses out-of-pocket. After the treatment, they submit all the bills and documents to the insurance company as proof of medical emergency and payment. 

The insurance company then offers financial coverage to the policyholder in the form of reimbursement.

Corporate Health Insurance Claim Process: Cashless Claim

1. Visit the nearest hospital or any hospital of your choice for medical treatments. With the new rule, you can visit any hospital, not only network hospitals, for your treatment, hospitalisation and therapy. 
2. Contact your group medical insurance provider. Inform the provider regarding medical treatment, hospitalisation and expenses. You may also inform the company before getting hospitalised if you have a planned hospitalisation. If it is a medical emergency, you should inform the insurer as soon as possible. 
3. When you reach the hospital, submit or present your policy identity card to the front desk. Fill out the pre-authorisation form provided by the hospital in order to file for a cashless claim. 
4. This form will be sent to the insurance company under your group medical insurance identity card. 
5. The insurance company will inspect the policy form, verify the authenticity of documents and analyse coverage capacity and further benefits.
6. If the company approves the cashless claim on your group health insurance policy, your hospital bills will be paid by the insurance company. The amount will be provided based on the coverage, scope, add-ons, sum-insured deductibles and sub-limits mentioned in your policy. 
7. If the claim is rejected, read the rejection letter. If you think you deserve financial coverage, re-apply. 

Corporate Health Insurance Claim Process: Reimbursement Claim

1. Reach the nearest hospital for your medical treatment or hospitalisation. If you have made an appointment, make the payment when you reach the front desk. Keep the bill with you.
2. Inform the insurance company or third-party administrator about your hospitalisation, treatment or other medical expenses within the first 24 hours of being hospitalised. 
3. You can file a reimbursement claim form online or offline. Under your GHI policy, the insurance provider or TPA will provide you with a claim number. 
4. You will receive bills for medical treatment, hospitalisation, pharmaceuticals and doctor visits. 
5. Submit these bills and other important documents to your insurance company. The company will verify the claim, assess its authenticity, analyse the policy’s coverage and then reject or approve the claim accordingly.
6. If your reimbursement claim under your group health insurance policy is approved, the insurance company will directly send the covered amount to the linked bank account.
7. If your reimbursement claim is rejected, read the rejection letter and reflect on your mistake. If you think you deserve to receive the reimbursement, contact the insurer and re-apply. 

Note: Make sure you keep important documents like ID proof, address proof, policy identity card, filled claim form, pathology reports, bills and discharge summary.

Final Thoughts

Understanding the claim process in a GHI policy is essential if you want to utilise it. Whether you opt for cashless claims or reimbursement claims, you need to understand how the settlement process is done. 

Knowing the steps and being cognisant of the intricacies of claim settlement helps you save time and reduces stress. This blog will help you navigate through the claim process with confidence.