Group Health Insurance

A reimbursement claim for group health insurance can be made if the policyholder decides to go to a hospital of his/her choice which is a non-empaneled hospital. In such a case, cashless hospitalisation cannot be availed.  In some cases, people also go for a reimbursement option, where the insurer is taking time to settle the network hospital claim due to non-availability of documents. In such a situation, they can pay all medical bills and later approach the insurer for reimbursement.

Once you receive your group health insurance policy document, carefully read it to know about all the documents which are required to be submitted for the reimbursement. While filing a claim, make sure to notify your group health insurer within 48 hours of admission in a network or non-network hospital. After the hospitalisation, you will have to pay all the medical expenses directly to the hospital.

On discharge, make sure to collect all the relevant documents, including invoices, medical reports, and discharge certificate in original from the hospital.

List of documents for group health claim reimbursement:

  • Duly filled and signed claim form
  • Doctor’s prescription advising the admission
  • Discharge card issued by the hospital
  • Final hospital bill in original
  • Medical investigation report
  • Medical bills with supporting prescriptions
  • Invoice for implants if used in surgery
  • Other bills, or documents related to the treatment
  • FIR in case of road traffic accidents
  • Cancelled cheque issued by the insurer where the payment will be made through NEFT

Most group health insurers offer a policy with clauses like deductible and co-payment. Here, deductible means that some part has to be paid first by the policyholder before the insurance company takes over and covers the remaining claim. Similarly, co-payment means that the insurer will share the claim burden and co-pay a predetermined amount.

Therefore, if your group mediclaim insurance policy has a deductible limit of Rs 5,000, then it means you would have to pay Rs 5,000 first before the insurer settles the remaining claim amount. Likewise, if we assume that there is a co-pay of 5%, it means you will pay 5% of the claim amount and the insurer will pay the remainder.

Remember, if you have your entire claim settled under a group health insurance policy, you can’t approach your personal health insurer to settle the claim. However, if half of your claim is settled by your group insurer, the remaining can be settled by the personal health insurance policy.

Case Study 1

Working as a Senior Accountant with KYC Motors Ltd. Mr. Raj Prakash has been living in Delhi for the last ten years. Nearly three years ago, he got married and  a few months ago a little angel named ‘Kavya’, his adorable daughter, came into the couple’s life. As KYC Motors was covering all its employees and their family members under group health insurance, Raj twice got his group mediclaim cover revamped— first, when he got married and second, after the birth of his daughter. Last year, his wife was hospitalised due to dengue.

As his wife was covered under his employee health insurance policy, he immediately informed his insurer and paid all the medical expenses, which came to Rs 35,000. He approached his group health insurer to reimburse the bill and submitted documents like claim form, doctor’s prescriptions, medical investigation report, medical bills, etc. His group insurance came with a deductible of Rs 5,000, therefore, he paid Rs 5,000 from his pocket, and the remaining Rs 30,000 was reimbursed by his insurer.

Case Study 2

It was the happiest day in Rahul’s life when he was blessed with a son, Arthav. After completing all the formalities and paying medical expenses, he brought his wife, Shreya, and son home. Rahul’s family members had planned a big welcome for the baby and new parents. The family and friends congratulated the couple.

Rahul, a 30-year old software engineer, was working in Pune for the last eight years. As his employer was offering corporate health insurance cover, he approached the insurer to settle the medical expenses related to the delivery. Due to some medical complications, Shreya had a C-section delivery, which also increased the total medical expenses to Rs 70,000. Rahul paid the expenses and later approached the insurer for reimbursement.

As his group health insurer was offering maternity coverage up to Rs 40,000, for the remaining Rs 30,000 (70,000-40,000) expenses, he contacted his family health insurance provider. Around five years back, when he got married, he bought a family floater health insurance with maternity benefits of Rs 50,000. The policy came with a waiting period of 3 years for maternity coverage, which was now over, and therefore, his family floater provider settled the remaining bill of Rs 30,000 after scrutinising documents like claim form, final discharge form, original medical reports, etc.

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