How to File a Claim under a Group Mediclaim Policy in India?

Group health insurance offers medical coverage to a specific group of people. The group mediclaim policy is generally provided by the employer in order to indemnify the employee against any disease or injury. In case of a medical emergency, the employee may obtain treatment. In addition, the employee may also seek compensation from the insurance company for the medical bills he paid to the hospital. Therefore, a policyholder must understand the claim process under the group mediclaim policy in India.

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Claim Process under Group Mediclaim Policy in India for Cashless Treatment

The policyholder may follow the below-mentioned steps for the cashless treatment at the hospital mentioned in the insurance contract.

Pre-authorisation Form

The policyholder is required to fill out the pre-authorisation form. The form shall be filled in at the hospital's TPA (Third Party Administrator) desk. TPA is an agent of the health insurance company. It plays the role of mediator between the insurance company and the policyholder.

Pre-approval of the Claim

The TPA shall inform the insurance company about the pre-approval of the claim.

Initial Amount

The insurance company shall receive the approval with some initial amount.

Settlement

Once the treatment of the policyholder in the hospital is done, the final settlement shall be done according to the terms and conditions specified in the insurance deed.

Claim Process under Group Mediclaim Policy in India for Reimbursement Claim

The policyholder may follow the steps below to reimburse his claim under the group health insurance plan.

Inform the Insurer

The policyholder must inform the insurance company within 24 hours of hospitalisation. Time plays a crucial role in reimbursement claims in every insurance policy. Therefore, the policyholder must understand the essence of time and inform the insurance company accordingly.

Submission of the Claim Form and Relevant Documents

The claim process under the group mediclaim policy in India includes submitting the claim form and relevant documents. The policyholder must obtain the claim form from the insurance company. He must fill in the correct details in the claim form. In addition, he must submit the necessary documents and the claim form within seven days of discharge from the hospital.

Collect Original Document

The policyholder must collect the original copies of reports, bills and discharge summaries. These documents must be submitted along with the essential document required to be submitted with the claim form.

Process of Claim

Based on the claim form and documents provided by the policyholder, the insurance company shall process the claim. In addition, the claim shall be settled based on the terms and conditions mentioned in the insurance contract.

Cancelled Cheque

The policyholder must provide a cancelled cheque on which account he wishes to receive the amount for his claim.

Settlement of Claim

The insurer shall transfer the claim amount within 15 days after the insured provide the details.

Disclaimer: The insurance company will not provide compensation unless all the required documents are submitted by the insured to process the claim.

Documents for Making a Claim

To understand the claim process under group mediclaim policy in India, the policyholder must understand the required documents to be submitted to the insurance company. The claim process under the group mediclaim policy in India mandates the policyholder to submit the necessary documents and the form.

The policyholder must submit the following documents:

  • The duly filled along with the sign of the appropriate doctor
  • Investigation report
  • Prescription allotted by doctor
  • Medical report of the policyholder
  • Final bill
  • Police report in case of an accident
  • Cash memos
  • Discharge summaries given by the doctor

Conclusion

Group mediclaim policy is generally provided to the employee of a company or organisation. The employee may raise a claim in case of any injury sustained by him. The policyholder must follow the prescribed steps to file the claim under the group health insurance.

Written By: PolicyBazaar - Updated: 22 August 2023

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