Group Health Insurance

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Claiming reimbursement under a Group Health Policy

If you are covered by a group health insurance plan, you might have to claim reimbursement for medical expenses if you go to a hospital that is non-empanelled (or not a network hospital). You cannot avail cashless hospitalisation at non-empanelled hospitals. Another reason for claiming reimbursement could be because the insurer takes time to settle a network hospital claim. This could be because necessary documents are not available at discharge. In such situations, you may have to pay the medical bills and then file for reimbursement.

Documents for claiming reimbursement under a Group Health Policy

Once you receive your group medical insurance policy document, read it carefully to understand what documents have to be submitted for the reimbursement. When filing a claim, remember to notify your group health insurer within 48 hours of admission to a hospital. Your insurer will usually need the following documents:

  • Claim form, duly filled and signed
  • Doctor’s recommendation for hospital admission
  • Discharge card issued by the hospital
  • Original of the final hospital bill
  • Medical investigation reports
  • Medical bills with supporting prescriptions
  • Invoice for surgical implants, if any
  • Any other bills or documents related to the treatment
  • FIR in case of road accidents
  • A cancelled cheque to provide account details in case the insurer is paying the reimbursement through NEFT

Timelines for receiving a reimbursement claim

The Protection of Policyholder Interest 2017 is a regulation that specifies how much time an insurer can take to settle reimbursement claims. Specifically, the insurer must settle the claim within 30 days of receiving the necessary documents. Further, if the insurer feels that an investigation is needed then the claim decision must be taken within 45 days of intimation. Also, the insurer will have to pay interest on any delays at the rate of 2% over the prevailing bank rate. Practically, settlement of reimbursement claims can take 2 to 4 months because insurers ask for clarifications on the bills received.

Understanding deductible and co-payment for claiming reimbursement under a Group Health Insurance Policy

Sometimes, some group health insurers apply a deductible or co-pay for reimbursement claims. Here, deductible means that you have to pay some part of the medical expense. For instance, if your group mediclaim policy has a deductible of Rs 5,000, you would have to pay Rs 5,000 first before the insurer settles the remaining claim amount.

Another clause that some insurers include is co-payment. This means that the insurer will share the medical expenses and not pay the full amount. So, if an insurer has a co-pay of 5%, it means you will pay 5% of the claim amount and the insurer will pay the remaining.

Remember, if your entire claim is settled under a group health insurance policy, you cannot approach your personal health insurer to settle the same claim. However, if your group insurer settles only some part of your claim, you can have the remaining settled under your personal health insurance policy.

Case Study: How deductible works

Raj Prakash lives in Delhi and works for KYC Motors Ltd as a senior accountant. A few months ago, he and his wife had a baby girl, Kavya. KYC Motors covers all its employees and their family members under group health insurance. Accordingly, Raj has revamped his group mediclaim twice — first, when he married and second, when his daughter was born.

Last year, Raj’s wife had dengue and was hospitalised. Raj’s employee health insurance policy covered his wife too. So, he immediately informed his insurer. He paid the medical bills, which totalled Rs 35,000 and approached the insurer to reimburse the bill. In support of his claim, he submitted a claim form, doctor’s prescriptions, medical investigation reports, medical bills, etc. His group insurance came with a deductible of Rs 5,000, which meant he had to pay Rs 5,000 and the insurer reimbursed him the rest.

Case Study: Splitting reimbursement

Rahul, 30, is a software engineer, who has been working in Pune for the past eight years. His employer offers corporate health insurance cover. Around five years ago, when Rahul married Shreya, he bought a family floater health insurance.

Recently, Shreya gave birth to their child, Atharv. Due to some medical complications, she had a C-section, which brought the total medical expenses to Rs 70,000. Rahul paid the expenses and later approached the group health insurer for reimbursement. The insurer offered maternity coverage of only Rs 40,000. Rahul’s family health insurance had maternity benefits of Rs 50,000. His family insurance provider settled the remaining bill of Rs 30,000 after scrutinising documents like claim form, final discharge form, original medical reports, etc.