What documents are required while making a claim under a Group Mediclaim Policy or GMC?

A group mediclaim policy (also called a Group Health Insurance policy) covers a group of individuals against medical contingencies. The policy is issued to a registered group and covers all the individuals who are members of the group. A group mediclaim policy provides affordable coverage and is easy to avail of. In a medical emergency, when the covered member is hospitalised, a claim can be made under the policy and the policy would cover the medical expenses incurred on such hospitalisation. 

To make a claim under a group mediclaim policy, the insurance company should be informed immediately about the claim. If the member has sought treatment at a network hospital, the claims are settled on a cashless basis. However, if the member is admitted to a non-network hospital for treatments, claims would be settled on a reimbursement basis. In a reimbursement claim, the insured would have to pay for the medical expenses and then the mediclaim policy would reimburse the costs incurred. 

Whether the claim is cashless or settled on a reimbursement basis, the insurance company usually requires a set of documents for processing the claim. These documents include the following –

  • The claim form. The claim form should be filled in stating the complete details of the insured member and the policy. 
  • To avail cashless treatments, the employee should fill up a pre-authorization form and submit it to the insurance company. Only when the form is submitted would the insurance company approve cashless claims. If the insured member is being hospitalised for a planned treatment, the pre-authorization form should be filled and submitted with the insurance company at least 3-4 days in advance. However, in case of emergency hospitalisation, the form should be filled and submitted within 24 hours of hospitalisation. If the insured member is seeking treatment in a non-network hospital, it would qualify for a reimbursement claim and in that case a pre-authorization form would not be required.
  • The original medical bills associated with the treatment taken by the insured should be submitted to the insurance company.
  • All the investigative reports of the insured would also be required to assess the cause of illness and the treatments taken thereof.
  • Prescriptions of the doctors who were consulted for the treatment or illness would be required
  • The hospital bill should be submitted in original which should show the detailed  break-up of the different costs incurred on treatments
  • In case of accidental hospitalisation, a police FIR should be filed and the same should be submitted to the insurance company
  • The cash memos of medical costs, if any, should also be submitted
  • The Discharge Summary issued by the hospital after the insured is discharged would be required in case of reimbursement claims.

Besides these documents, the insurance company might require other documents too depending on the claim. All the documents should be duly submitted to the insurance company so that the claim is processed and settled easily and quickly.

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