What Is The Claim Process In A Group Health Insurance Policy?

Group health insurance, also called group mediclaim insurance policy, is an employer-employee insurance plan provided by the employer. Under group insurance coverage, employees and their dependents, if required, are covered under one policy in times of emergencies.

With group health insurance, the premium payments are either completed solely by the employer or a partial contribution is collected from the employees, making it a more affordable option for individual health insurance plans.

However, one similar aspect of all types of health insurance plans is the claim procedure. Regardless of whether you are exploring an individual or a group health insurance claim process, you must know the basics to complete it successfully.

Here is all you need to know.

For most group medical insurance policy claims, there are primarily two types of claim options: cashless and reimbursement claims. Let us look at each of them below, along with their claim settlement processes.

Cashless Claims

• Under the group mediclaim policy, when an employee files a claim with the insurance provider and chooses a cashless claim, they do not have to worry about paying the hospital bills once the treatment is completed.

• In simple words, with a cashless claim, the medical expenses incurred during hospital admission and treatment are settled between the hospital and the insurer.

• However, in some cases, a third-party administrator (TPA) is involved in the entire process to facilitate faster solutions.

Let us look at the cashless claim process below:

• Find the nearest hospital approved for cashless claims. With Tata AIG, you can avail of a cashless claim at any hospital of your choice.

• Notify the insurance provider or TPA regarding the hospitalisation. For pre-planned treatments, update 48 hours prior to hospitalisation, and for emergencies, notify within 48 hours.

• Submit the health card provided by the employer/TPA at the chosen hospital.

• Fill out the group medical claim form given by the hospital to add all the necessary details regarding the treatment and yourself.

• Once done, the hospital will share the claim form with the insurance provider for claim approval.

• The insurer will then review the claim details to approve or reject the same.

• Once the claim is approved, the treatment will be completed, and the bills for it will be shared with the insurer for settlement.

Reimbursement Claims

• Another type of claim settlement within a group insurance policy is a reimbursement claim. In this claim process, the medical bills are first settled by the insured employee, and then the same is reimbursed after proper documentation and proof submission.

• Let us look at the reimbursement claim process below.

• Notify the insurer or TPA within 24-48 hours of hospitalisation regarding the treatment.

• File a claim and collect the claim number for reference and claim status tracking.

• Visit any hospital and get the treatment completed. You must also fill out the group medical claim form given by the hospital.

• Collect all the treatment bills and other necessary receipts or invoices.

• Submit the group medical claim form and the necessary documents to the insurer/TPA.

• They will then review all the claim details and bills and request any additional documentation, if necessary, before approving a claim reimbursement amount.

• Once the amount is approved, the same will be reimbursed to your bank account.

Cashless Claims

• Government identification card of the employee (Aadhaar card, PAN card, etc.).

• Employee insurance health card.

• A duly filled and signed group medical claim form.

• Proof of hospital admission (form available at the hospital).

• All hospital bills

• Bank statements of the insured employee.

• Additional payment receipts for any non-hospital expenses relevant to the treatment.

Reimbursement Claims

• A duly filled and signed group medical claim form.

• Employee insurance health card.

• A signed certificate from the authorised doctor.

• An investigation report and FIR in case of accident or third-party-inflicted health issues.

• All the relevant doctor and hospital reports regarding the completed treatment.

• All hospital bills, pharmacy expenses, and other relevant payment proof to validate the medical treatment.

• A hospital discharge card.

• The first tip is to read and understand the group health insurance policy terms and conditions. This is necessary as it helps file a claim with better knowledge while reducing any gaps due to incorrect information.

• Check for the policy inclusions and exclusions to know what to expect at the time of claim filing. This will also assist you in planning your expenses in case of treatments under the excluded category.

• Next, check for the waiting period for certain pre-existing health conditions and diseases. Even though most group health insurance plans offer coverage for this since day 1 of the policy, assessing the same in advance can ensure faster claim settlements.

• When assessing the policy terms, also review the claim co-payment clause to ensure it is favourable. Co-payment is the percentage of the medical expenses that will be taken care of by the insured. This helps with financial management during the claim for faster settlement with the insured.

When you file a claim with your insurance provider, you must check with the insurer regarding the claim tracking process. For claims with Tata AIG, you must follow the steps mentioned below.

• Visit the Tata AIG website.

• From the top bar, click on “Claims”.

• You will be redirected to another webpage.

• Here, find and select the “Track Claim” option.

• Click on “Health” from the list of options.

• Enter your registered mobile number associated with the group health insurance policy.

• Click on “Submit” to view the claim status.

• For offline claim status tracking, you can call us at 1800-266-7780 and request an update by providing your claim reference number.

Assess the Coverage - The first thing to compare when choosing a group health insurance policy is the type of coverage available with the insurer. It is crucial to choose a plan that offers extensive coverage to extend maximum support to the employees.

Review the Inclusions and Exclusions - The next thing to assess is the list of inclusions and exclusions attached to the policy. This is a necessary criterion as you must choose a group health insurance policy that fulfils the needs of the employees; otherwise, it will not benefit them.

Claim Settlement Ratio - You must also review the claim settlement ratios of different insurers to get an idea of their speed of settlement. This will help you assess the insurer's overall efficiency.

Market Reviews - To learn more about different insurers, you must also check their online reviews from previous customers and other testimonials to ensure you pick the one offering the best services.

Customer Support - Insurance providers must Have a proper customer support team or department to help policyholders with urgent and other queries in a reasonable time.

Online Convenience - Choose an insurer that offers ample online convenience for policyholders. This will ensure they can access their policy and file claims from anywhere in the world without any hassle.

A group health insurance policy is a significant investment in employee health and well-being and company growth and expansion. Employees can benefit from a financial safety net that ensures ample coverage in times of need.

Employers, on the other hand, benefit from employee motivation and retention. While choosing group health insurance, pick an insurer that offers extensive coverage at affordable rates.

Tata AIG group health insurance plans are designed to offer maximum coverage to all the employees within the policy with ample customisation flexibility and the ease of group health insurance claim process online with the option of a cashless claim at any hospital in India.

#GoCashless

For added business security, you can also explore our various SME insurance plans, which offer coverage for a wide range of situations, such as burglary and fire.

Can I file a cashless claim at any hospital of my choice?

After the General Insurance Council’s decision to make cashless treatment available at all authorised hospitals for health insurance policyholders, you can now file a cashless claim at any authorised hospital of your choice.

What are the reasons behind claim rejections?

Your health insurance claim can be rejected due to the following reasons -

Incomplete or incorrect claim form

Incomplete documentation

Required treatment excluded from the policy coverage

Treatment bills exceeding policy limits

What to do if I lose my group health insurance card?

If you lose your group health insurance card, you can update the insurer or third-party administrator about the same. They will then assist you in providing a temporary card or other relevant solution to file a claim on time.