Health insurance claim process - A guide to group health insurance claims

A group health insurance claim is a request that a health insurance policyholder (employee) submits to a health insurance company to get the services mentioned in their health plan/policy during hospitalization or medical treatments. By sending this request, the health insurer is notified to initiate the claim process.

How to claim medical insurance for your group policy

There are two types of claims in group health insurance. They are cashless claims and reimbursement claims.

Cashless claim

As the name suggests, it frees us from handling money during medical emergencies. In a cashless claim, the insurer settles the medical bills directly with the hospital itself. This is applicable only if the policyholder is admitted to a network hospital.

Also read: Network hospitals and cashless treatment

Cashless claim during planned hospitalization

In the case of surgery, hospitalization is planned. Whenever a hospitalization is planned, the policyholder must inform the TPA or network hospital at least 72 hours prior.

Cashless claim for emergency hospitalization

For availing of a cashless claim for emergency hospitalization, you will have to inform the insurer or TPA within 24 hours of hospitalization.

Reimbursement claim

In a reimbursement claim, once the insured is admitted to a hospital, the bills are paid from your pockets. Later, the insurance company will reimburse the claim amount to you once you provide the necessary documentation.

This is mostly the case when the policyholder goes to a hospital that is not in the network hospital list of the insurer. However, the claims are settled by evaluating the credibility of the documents you provide.

This is why it is important to choose an insurer with an extensive hospital network and a high claim settlement ratio. A claim settlement ratio suggests the percentage of claims settled by the insurance company to the policyholders in a financial year. The higher the ratio, the higher the chance of your claims being settled.

Cashless claim process

The claim process might vary depending on your insurer. Below is the common claims process for cashless.

1. The policyholder provides the details of the insurance policy taken along with the ID card provided by the insurer in the network hospital.
2. The hospital will send the treatment and insurance details to the TPA.
3. The TPA verifies and sends the pre-authorization letter to the hospital.
4. When the patient gets discharged the bills are settled by the insurer. The policyholder will only have to pay if there are any minor expenses that are not covered in the policy.

The process remains the same for planned and emergency hospitalization. However, the claim intimation must be done within the time limit mentioned above.

Reimbursement claim process

The reimbursement claims can be initiated in a hospital of your choice. The general procedure includes

• The insured or the policyholder has to pay all the medical bills and other costs involved in the hospitalization. Make sure you keep all the bills safely for the claim.
• Submit the original bills to the insurer along with a duly filled claim form. The claim forms are mostly available on the website of the insurer or their offices.
• After this, the claim request is verified and processed according to the terms and conditions of the policy.
• Once the claim is verified and the bills are credible the insurer settles the payment to the account of the policyholder.

Also read: Difference between OPD and IPD and its claims

Download claim forms

Documents required for reimbursement claim

• Duly filled claim form. Available on the website or the offices of the insurer as well.
• The health insurance ID card provided by the insurer.
• After this, the claim request is verified and processed according to the terms and conditions of the policy.
• A valid unique identity card like Aadhar, Voter Id, etc.
• All the original medical bills and pharmacy bills.
• Doctor consultation and prescription papers.
• Investigation report
• Discharge summary from the hospital.
• A medical certificate signed by the doctor in charge.
• For accidents, FIR or MLC (Medico-Legal Certificate) copy
• Other relevant documents.

What is claim number in health insurance?

Claim number is a number given by the insurer after a claim is raised. Every claim number is unique.

Claim intimation

Claim intimation is informing your insurer or TPA when you are going to raise a claim. This allows them to provide you with insurance services.

• Immediately after the policyholder or the attendant of the insured intimates the claim to the insurance provider, the insurer verifies the policy and the coverage of that policy.
• After the verification process by a field doctor, the pre-authorization form is submitted and the cashless claims are approved.
• This authorization process can even get canceled if the details mentioned are incorrect.
• The claims must be filed within 30 days of discharge from the hospital
• The insured will have to pay for all other expenses which are not covered under their health insurance policy.

Claim limit

Claim limit does not mean a limit on the number of claims. It is limit on the amount/sum insured. You can file any number of claims but only up to the limit of your total sum insured. If you have a sum insured of 5 lacs, then you can file multiple claims till you reach the 5 lac limit. Once you exhaust the sum insured, you won't be able to raise claims.

Check claim status