{"id":1226,"date":"2017-06-13T08:14:30","date_gmt":"2017-06-13T08:14:30","guid":{"rendered":"https:\/\/pamstaging.securenow.in\/insuropedia\/?p=1226"},"modified":"2026-03-20T07:05:36","modified_gmt":"2026-03-20T07:05:36","slug":"claiming-reimbursement-under-group-health-policy","status":"publish","type":"post","link":"https:\/\/securenow.in\/insuropedia\/claiming-reimbursement-under-group-health-policy\/","title":{"rendered":"How to file reimbursement claim under a Group Health Insurance Policy?"},"content":{"rendered":"<div id=\"bsf_rt_marker\"><\/div><p>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 of cashless hospitalisation at non-empanelled hospitals. Another reason for claiming reimbursement could be that the insurer takes time to settle a network hospital claim. This could be because the necessary documents are not available at discharge. In such situations, you may have to pay the medical bills and then file for reimbursement.<\/p>\n<h2 data-path-to-node=\"5\">Key Takeaways<\/h2>\n<ul data-path-to-node=\"6\">\n<li>\n<p data-path-to-node=\"6,0,0\"><b data-path-to-node=\"6,0,0\" data-index-in-node=\"0\">Documentation is King:<\/b> Reimbursement depends entirely on original physical documents. Missing bills, prescriptions, or a discharge summary can lead to significant delays or claim rejection.<\/p>\n<\/li>\n<li>\n<p data-path-to-node=\"6,1,0\"><b data-path-to-node=\"6,1,0\" data-index-in-node=\"0\">Notification is Mandatory:<\/b> Even if you intend to pay upfront and claim later, you must inform the insurer shortly after admission to ensure the claim remains valid.<\/p>\n<\/li>\n<li>\n<p data-path-to-node=\"6,2,0\"><b data-path-to-node=\"6,2,0\" data-index-in-node=\"0\">Legal Timeframes:<\/b> Under the Protection of Policyholder Interest 2017 regulations, insurers are legally bound to settle claims within 30 days of receiving all necessary paperwork.<\/p>\n<\/li>\n<li>\n<p data-path-to-node=\"6,3,0\"><b data-path-to-node=\"6,3,0\" data-index-in-node=\"0\">The Deductible\/Co-pay Gap:<\/b> Many group plans require the employee to bear a small portion of the cost. Always check your policy for a &#8220;Deductible&#8221; (your initial share) or &#8220;Co-payment&#8221; (your percentage share).<\/p>\n<\/li>\n<li>\n<p data-path-to-node=\"6,4,0\"><b data-path-to-node=\"6,4,0\" data-index-in-node=\"0\">Policy Coordination:<\/b> You cannot profit from insurance. You can only use a second policy (like a personal health plan) to cover the &#8220;shortfall&#8221; or balance that the first policy did not pay.<\/p>\n<\/li>\n<\/ul>\n<h2>Documents required for claiming reimbursement under Group Health Policy :<\/h2>\n<p>Once you receive your group medical insurance policy document, read it carefully to understand what documents have to be submitted for 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:<\/p>\n<ul>\n<li>Claim form, duly filled and signed<\/li>\n<li>Doctor\u2019s recommendation for hospital admission<\/li>\n<li>Discharge card issued by the hospital<\/li>\n<li>Original of the final hospital bill<\/li>\n<li>Medical investigation reports<\/li>\n<li>Medical bills with supporting prescriptions<\/li>\n<li>Invoice for surgical implants, if any<\/li>\n<li>Any other bills or documents related to the treatment<\/li>\n<li>FIR in case of road accidents<\/li>\n<li>A cancelled cheque to provide account details in case the insurer is paying the reimbursement through NEFT<\/li>\n<\/ul>\n<h3>Timelines for receiving a reimbursement claim<\/h3>\n<p>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.<\/p>\n<h3>Deductible and co-payment for claiming reimbursement under a Group Health Insurance Policy :<\/h3>\n<p>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.<\/p>\n<p>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.<\/p>\n<p>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.<\/p>\n<h3>Case Study: How deductible works in Group Health Insurance?<\/h3>\n<p>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 \u2014 first, when he married and second when his daughter was born.<\/p>\n<p>Last year, Raj\u2019s wife had dengue and was hospitalised. Raj&#8217;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\u2019s 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.<\/p>\n<h3>Summary Table: Reimbursement in Group Health Insurance<\/h3>\n<table data-path-to-node=\"3\">\n<thead>\n<tr>\n<td><strong>Feature<\/strong><\/td>\n<td><strong>Details<\/strong><\/td>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td><span data-path-to-node=\"3,1,0,0\"><b data-path-to-node=\"3,1,0,0\" data-index-in-node=\"0\">Primary Trigger<\/b><\/span><\/td>\n<td><span data-path-to-node=\"3,1,1,0\">Treatment at a non-network hospital or delayed cashless approval.<\/span><\/td>\n<\/tr>\n<tr>\n<td><span data-path-to-node=\"3,2,0,0\"><b data-path-to-node=\"3,2,0,0\" data-index-in-node=\"0\">Notification Window<\/b><\/span><\/td>\n<td><span data-path-to-node=\"3,2,1,0\">Usually within <b data-path-to-node=\"3,2,1,0\" data-index-in-node=\"15\">48 hours<\/b> of hospital admission.<\/span><\/td>\n<\/tr>\n<tr>\n<td><span data-path-to-node=\"3,3,0,0\"><b data-path-to-node=\"3,3,0,0\" data-index-in-node=\"0\">Settlement Deadline<\/b><\/span><\/td>\n<td><span data-path-to-node=\"3,3,1,0\">30 days post-document submission (45 days if investigation is required).<\/span><\/td>\n<\/tr>\n<tr>\n<td><span data-path-to-node=\"3,4,0,0\"><b data-path-to-node=\"3,4,0,0\" data-index-in-node=\"0\">Penalty for Delay<\/b><\/span><\/td>\n<td><span data-path-to-node=\"3,4,1,0\">Insurer must pay interest at <b data-path-to-node=\"3,4,1,0\" data-index-in-node=\"29\">2% above the bank rate<\/b> for delayed payments.<\/span><\/td>\n<\/tr>\n<tr>\n<td><span data-path-to-node=\"3,5,0,0\"><b data-path-to-node=\"3,5,0,0\" data-index-in-node=\"0\">Shared Costs<\/b><\/span><\/td>\n<td><span data-path-to-node=\"3,5,1,0\">Claims may be subject to <b data-path-to-node=\"3,5,1,0\" data-index-in-node=\"25\">Deductibles<\/b> (fixed amount) or <b data-path-to-node=\"3,5,1,0\" data-index-in-node=\"55\">Co-pays<\/b> (percentage).<\/span><\/td>\n<\/tr>\n<tr>\n<td><span data-path-to-node=\"3,6,0,0\"><b data-path-to-node=\"3,6,0,0\" data-index-in-node=\"0\">Secondary Claims<\/b><\/span><\/td>\n<td><span data-path-to-node=\"3,6,1,0\">Leftover balances can be claimed from a personal policy after the group insurer pays.<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3>Case Study: Splitting reimbursement under Group Health Insurance<\/h3>\n<p>Rahul, 30, is a software engineer, who has been working in Pune for the past eight years. His employer offers corporate health insurance coverage. Around five years ago, when Rahul married Shreya, he bought a family floater health insurance.<\/p>\n<p>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\u2019s 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 the claim form, final discharge form, original medical reports, etc.<\/p>\n<h3 data-path-to-node=\"8\">Frequently Asked Questions (FAQs)<\/h3>\n<h4 data-path-to-node=\"9\"><b data-path-to-node=\"9\" data-index-in-node=\"0\">1. Why can&#8217;t I use the cashless facility at every hospital?<\/b><\/h4>\n<p data-path-to-node=\"9\"><strong>A)<\/strong> Insurance companies have &#8220;Network Agreements&#8221; with specific hospitals. If a hospital is not on that list (non-empanelled), they do not have a billing arrangement with the insurer, requiring you to pay the bill and seek reimbursement later.<\/p>\n<h4 data-path-to-node=\"10\"><b data-path-to-node=\"10\" data-index-in-node=\"0\">2. What should I do if the insurer takes more than 30 days to pay me back?<\/b><\/h4>\n<p data-path-to-node=\"10\"><strong>A)<\/strong> If all documents were submitted and there are no pending clarifications, the insurer is liable to pay interest on the delayed amount at a rate of 2% over the prevailing bank rate. You can highlight this regulation to their grievance officer.<\/p>\n<h4 data-path-to-node=\"11\"><b data-path-to-node=\"11\" data-index-in-node=\"0\">3. Is a &#8220;cancelled cheque&#8221; really necessary for a health insurance claim?<\/b><\/h4>\n<p data-path-to-node=\"11\"><strong>A)<\/strong> Yes. Insurers use the details on the cancelled cheque (account number and IFSC code) to ensure the money is sent via NEFT to the correct bank account, preventing payment errors.<\/p>\n<h4 data-path-to-node=\"12\"><b data-path-to-node=\"12\" data-index-in-node=\"0\">4. Can I claim the cost of a surgery if I lost the original hospital bill?<\/b><\/h4>\n<p data-path-to-node=\"12\"><strong>A)<\/strong> It is very difficult. Insurers strictly require <b data-path-to-node=\"12\" data-index-in-node=\"123\">original<\/b> bills and discharge summaries for reimbursement to prevent double-claiming. If you lose them, you may need to provide certified duplicates along with an indemnity bond, though approval is not guaranteed.<\/p>\n<h4 data-path-to-node=\"13\"><b data-path-to-node=\"13\" data-index-in-node=\"0\">5. What happens if my group insurance only covers part of my maternity bill?<\/b><\/h4>\n<p data-path-to-node=\"13\"><strong>A)<\/strong> As shown in the case studies, if your employer&#8217;s plan has a &#8220;sub-limit&#8221; (e.g., it only pays Rs 40,000 for a Rs 70,000 bill), you can take the &#8220;Settlement Summary&#8221; from the first insurer and submit it to your personal insurance provider to claim the remaining Rs 30,000.<\/p>\n<p><script type=\"application\/ld+json\">\n{\n  \"@context\": \"https:\/\/schema.org\",\n  \"@type\": \"FAQPage\",\n  \"mainEntity\": [\n    {\n      \"@type\": \"Question\",\n      \"name\": \"Why can't I use the cashless facility at every hospital?\",\n      \"acceptedAnswer\": {\n        \"@type\": \"Answer\",\n        \"text\": \"Insurance companies have \\\"Network Agreements\\\" with specific hospitals. If a hospital is not on that list (non-empanelled), they do not have a billing arrangement with the insurer, requiring you to pay the bill and seek reimbursement later.\"\n      }\n    },\n    {\n      \"@type\": \"Question\",\n      \"name\": \"What should I do if the insurer takes more than 30 days to pay me back?\",\n      \"acceptedAnswer\": {\n        \"@type\": \"Answer\",\n        \"text\": \"If all documents were submitted and there are no pending clarifications, the insurer is liable to pay interest on the delayed amount at a rate of 2% over the prevailing bank rate. You can highlight this regulation to their grievance officer.\"\n      }\n    },\n    {\n      \"@type\": \"Question\",\n      \"name\": \"Is a \\\"cancelled cheque\\\" really necessary for a health insurance claim?\",\n      \"acceptedAnswer\": {\n        \"@type\": \"Answer\",\n        \"text\": \"Yes. Insurers use the details on the cancelled cheque (account number and IFSC code) to ensure the money is sent via NEFT to the correct bank account, preventing payment errors.\"\n      }\n    },\n    {\n      \"@type\": \"Question\",\n      \"name\": \"Can I claim the cost of a surgery if I lost the original hospital bill?\",\n      \"acceptedAnswer\": {\n        \"@type\": \"Answer\",\n        \"text\": \"It is very difficult. Insurers strictly require original bills and discharge summaries for reimbursement to prevent double-claiming. If you lose them, you may need to provide certified duplicates along with an indemnity bond, though approval is not guaranteed.\"\n      }\n    },\n    {\n      \"@type\": \"Question\",\n      \"name\": \"What happens if my group insurance only covers part of my maternity bill?\",\n      \"acceptedAnswer\": {\n        \"@type\": \"Answer\",\n        \"text\": \"As shown in the case studies, if your employer's plan has a \\\"sub-limit\\\" (e.g., it only pays Rs 40,000 for a Rs 70,000 bill), you can take the \\\"Settlement Summary\\\" from the first insurer and submit it to your personal insurance provider to claim the remaining Rs 30,000.\"\n      }\n    }\n  ]\n}\n<\/script><\/p>\n<h4><b>About The Author<\/b><\/h4>\n<p><strong>Mayank Sharma\u00a0<\/strong><\/p>\n<p><strong>MBA Finance<\/strong><\/p>\n<p><span style=\"font-weight: 400;\">He is a professional who brings extensive knowledge and expertise to the field of group health insurance. He has dedicated 7years to helping individuals and businesses navigate the complexities of insurance. Having worked closely with numerous clients and insurance providers, he deeply understands the nuances of group health insurance policies. With a reputation for providing insightful and informative content, he leverages his industry experience to educate readers about the importance of group health insurance and its benefits. Through their articles, Mayank Sharma aims to empower individuals and businesses to make informed decisions about their healthcare coverage, ultimately promoting healthier and more secure communities.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>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 of cashless hospitalisation at non-empanelled hospitals. Another reason for claiming reimbursement could be that the insurer takes time to [&hellip;]<\/p>\n","protected":false},"author":5,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"om_disable_all_campaigns":false,"_lmt_disableupdate":"no","_lmt_disable":"no","_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[1,280],"tags":[48],"class_list":["post-1226","post","type-post","status-publish","format-standard","hentry","category-group-health-insurance","category-claims-group-health-insurance","tag-group-health-insurance"],"acf":[],"modified_by":"SecureNow","_links":{"self":[{"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/posts\/1226","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/users\/5"}],"replies":[{"embeddable":true,"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/comments?post=1226"}],"version-history":[{"count":23,"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/posts\/1226\/revisions"}],"predecessor-version":[{"id":35797,"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/posts\/1226\/revisions\/35797"}],"wp:attachment":[{"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/media?parent=1226"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/categories?post=1226"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/tags?post=1226"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}