Group Health Insurance

The claim process under group health insurance policy can be simply understood as the following:

In case of network hospitals

If you are visiting a network hospital, i.e., one that your health insurer has tied up with, you will be entitled to get cashless hospitalisation. It means, you just need to show your health card and avail cashless service. It is necessary to inform the insurer within 48 hours of admission or before discharge from the hospital/nursery home. Here, notification of claim means informing about a claim to the insurance company or TPA, specifying the timelines along with address/telephone number where the insurer can contact.

Though the group health insurance is available, it doesn’t mean the insured can have an unreasonable approach. The insured shall, without any delay, consult a medical practitioner and follow the advice and treatment and take all reasonable measures to curtail the quantum of any claim that might arise under the policy.

Cashless facility is available at network hospitals only. To avail of cashless treatment, the following procedures need to be complied with:

Before taking treatment and incurring medical expenses at a network hospital, the insured needs to inform the insurance company and request for pre-authorisation using the requisite form. After receiving the request from the insured and obtaining any extra documentation or information required, the insurer, if satisfied, sends an authorisation letter. The authorisation letter, the ID card issued to the policyholder along with the insurance policy and any other document that the insurer has specified must be produced to the network provider, as identified in the pre authorisation letter, at the time of admission.

If the above procedure is followed, the insured doesn’t need to directly pay for medical expenses as all the original bills and evidence of treatment in respect of the same shall be with the network provider. Note that, even if it is a pre-authorisation, it doesn’t mean that all expenses and costs will be covered by the insurance company. The insurer reserves all right to review each group health insurance claim for medical expenditure and coverage will be decided as per the terms and conditions of the policy. Insured shall be required to settle other expenses directly.

Sometimes it happens that a patient or family is in a rush to pay medical bills and later files for reimbursement even in the case of a network hospital. If this is the case, the insured should file the claim and any case within 30 days of discharge from the hospital and give all necessary details in writing to the insurer along with the original bills, receipts, and other documents upon which a group health insurance claim will be settled. Also, it is required to furnish necessary additional information and assistance as the insurer may need while dealing with the claim. The insured should be redy to make himself/herself available for medical examination by the insurer’s advisors as is often required.

In case of non- network hospitals

If the pre-authorisation as stated above, is rejected by the insurer or if the treatment is taking place in a non-network hospital, i.e., not in the network of the insurer, or if the insured doesn’t want to avail the cashless facility, then:

Insured should give written notification of a claim, immediately, and in any event within 48 hours of the illness or injury. It is necessary that the insured should consult a doctor, and follow all the recommended advice and treatment.

Insured person should within 30 days of discharge from the hospital submit documents, like original supporting documentation along with hospital bills, doctor’s prescription, medical bills, discharge summary from the hospital, pathological reports, death certificate, wherever required along with other necessary reports that the insurer may require before reimbursing the health insurance claim amount.

In the case of death of the insured, someone claiming on his/her behalf must inform the insurer in writing and send a copy of the post mortem (if applicable) within 14 days. In some cases, the insurer may waive off the usual periods for intimation and submission of documents in case any hardship is being faced by the policyholder or representative, however, such cases should be backed with documents.

Case Study: 1

Jayant, a 32- year old engineer with a multinational company, is covered under a group health insurance policy offered by his employer. A few months back, Jayant got admitted to a private hospital for hernia surgery. He chose a network hospital, i.e., the hospital where he got cashless treatment. He informed his group health insurer and requested for pre-authorisation. After receiving the request, the insurer sent an authorisation letter to a network provider. After this, Jayant did not pay anything to the hospital and the medical expenses were settled by the insurer directly with the hospital. However, as group health insurance came with a deductible of Rs 5,000, Jayant paid this amount and the remaining was settled by the insurer.

Case Study: 2

As a senior accountant, Mr. Rama Subramanian has been working with RJ Associates from the last four years. Along with benefits like free meals and cab, RJ Associates is also offering group health insurance to its over 200 employees. Last year, Rama was playing with his 3-year old son at home, when he started complaining of severe heart pain. Luckily, his younger brother was at home which, along with Rama’s wife Meenal, rushed him to a nearby hospital.

On the basis of the initial reports, doctors diagnosed it as a cardiac arrest and stressed upon emergency operation. Meenal signed some hospital forms and doctors conducted a life-saving operation and saved Rama. This sudden hospitalisation led to medical expenses of Rs 1.5 lakhs. Rama was kept in a hospital under doctor’s observation and was later discharged after two weeks. This emergency had created panic in Rama’s family to the extent that they forgot to inform the insurer and took him to a nearest non-network hospital.

However, after discharge when Rama was recuperating at home, he approached his group health insurer, filed a claim and submitted documents like duly filled claim form, doctor’s report, and investigation reports (X-rays and laboratory test). Upon receiving these documents, the insurance company scrutinised them and issued the signed discharge voucher in the name of Rama.


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