Group Health Insurance

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The process for filing a claim under a group health insurance policy depends on the hospital and the type of treatment.

Claiming health insurance in-network hospitals

A network hospital is one that has a tie-up with an insurer. Members covered under group health insurance can get cashless hospitalization from network hospitals. This means that the hospital will not charge you if you show your health card on our mobile app. However, reimbursement, which allows you to pay the hospital yourself and then file a claim with the insurer, can be done at any hospital.

For unplanned hospitalization

Inform your group medical insurer within 48 hours of being admitted. But certainly, before the hospital discharges you. Do file your final claim within 30 days of discharge. With your claim, submit original bills, receipts, doctor’s diagnoses, and the discharge summary. Moreover, there may be specific requirements for your group insurance. Additionally, insurers or third-party administrators (TPAs) could also ask for internal cases and previous illness reports.

For planned hospitalization

Contact the insurance company and fill out the pre-authorization form. Often, hospitals directly handle this form-filling. An essential part of the application is a medical diagnosis and a cost estimate. However, the insurer may ask for additional information. They will send you authorization if satisfied that a claim is payable. Use this authorization, the mediclaim card, and other documents specified to get admitted. So, with this approval, you do not need to pay directly for medical expenses. In fact, the network hospital will send the bills and evidence of treatment to the insurer just before your discharge.

After filing a claim under the group health insurance policy, an insurer will review a claim even if the treatment was previously approved and will decide cover based on the policy terms. Further, a hospital may insist on a deposit even if you have cashless approval. Often it may be best to pay the deposit and take a refund when the insurer issues the final payment approval to the hospital.

There are situations when you receive pre-authorization but the insurer withdraws this before discharge. This happens when the insurer is not satisfied that the treatment was consistent with the pre-approval. In such cases, you can still file for a reimbursement claim later.

Claiming health insurance in non-network hospitals

A non-network hospital does not have a tie-up with the insurer but, the filing and the claims process is similar to unplanned hospitalization in-network hospitals. Unfortunately, cashless procedures are not possible in non-network hospitals.

Inform the group health insurance provider within 48 hours of an illness or injury. After the hospital discharges you, file your claim within 30 days. Submit the original hospital bills, doctor’s prescriptions, hospital discharge summaries, and pathology reports. Insurers may ask for other documents as well.

If an insured person dies, their nominees must inform the insurer with a copy of the death certificate. Send a copy of the post-mortem, if applicable, within 14 days. However, if you are unable to file a claim within 30 days of discharge, you can still file a claim citing a credible reason.

Case Study 1: Cashless claim settlement

Jayant is an engineer with a multinational company that has a group health insurance policy. Some months ago, Jayant needed hernia surgery in a network hospital and requested his group health insurer for pre-authorization. The insurer approved Rs 75,000. The actual bill was Rs 70,000 and the insurer paid Rs 60,000. The deduction of Rs 10,000 was towards non-medical items such as registration charges and food for visitors. The insurer paid most expenses.

Case Study 2: Reimbursement claim

Mr Rama Subramanian works with RJ and Associates as a senior accountant and gets benefits such as free meals, and not only transport but also group health insurance. Last year, Rama was playing with his 3-year-old son at home when, suddenly, he had severe chest pain. Meenal, his wife, and his younger brother rushed him to a nearby non-network hospital. In the chaos, Rama’s family forgot to inform the insurer. The doctors diagnosed a cardiac arrest and advised an emergency operation. Meenal signed a consent form after which the doctors operated on and saved Rama. The cost for this sudden hospitalization was Rs 1.5 lakh.

Rama was in the hospital for two weeks. On discharge, he settled the hospital bill and returned home. After a few days, Rama filed a claim with his group health insurance provider. He submitted a claim form, a doctor’s report, and pathological reports (X-rays and laboratory tests). The insurer examined these documents, was satisfied and paid Rama directly.