Reimbursement Claim Under Group Insurance

Process of Reimbursement Claims

When you purchase a group health insurance policy, the insurance provides you with a list of network hospitals. These network hospitals ties-up with the insurance companies that eventually provide cashless claims to the policyholder.

However, if the policyholder chose to go to a non-network hospital for the treatment and raise a claim then he/she is not eligible to get a cashless claim instead he/she gets reimbursement for the amount paid for the treatment in the hospital.

Apart from this, there is another reason for reimbursement claims. In case the necessary documents are not presented at the time of discharge of the patient and eventually, it takes time to settle the claim then you will have to make the payment out of pocket and then claim for reimbursement.

So How Long Does Insurer Take To Reimburse?

Well, Protection of Policyholder Interest 2017 specifies the time an insurer can take to settle a reimbursement claim. The specified time for the insurer to settle the claim is within 30 days once all the necessary documents are submitted.

However, if the insurer needs to do an investigation then the claiming decision must be taken within 45 days from the initiated day. The insurer will also have to pay an interest of 2% in case of delay as per the bank rate. So, the settlement of reimbursement claims can take up to 4 months as an insurer can ask for clarification on the received bills.

What Are Those Necessary Documents?

While purchasing the group insurance policy, read it properly as to what documents you have to submit to get reimbursement claims. It is important to keep required documents ready to have a seamless reimbursement claim as you need to inform the insurer within 4 hours of admitting the patient to the hospital. Then your insurer will ask you to submit the following documents:

• Duly filled claim form
• Final hospital bill (Original copy)
• Doctor’s prescription recommending admission to a hospital
• Discharge card by hospital
• Medical bills
• Prescription supporting medical bills
• Surgical implant invoice, if any
• In case of a road accident, a copy of the FIR
• Cancelled cheque to provide account details if the insurance company is paying the reimbursement through NEFT

Apart from this, in a group health insurance policy, here are some other things that you should know about.

Deductibles & Co-payment Clause

Some group health insurance provides apply deductibles in the reimbursement process. Under this, the insured has to pay a small part of the paid amount to the insurer. For instance, if the group health insurance policy comes with a deductible amount of Rs 4000, then the insured will have to pay Rs 4000 to the insurer before the insurance company settles the claim.

Similarly, there is another clause called co-payment. The co-payment clause refers to the point where the insurer has to share the total paid amount instead of paying the full amount. If the insurer has a co-pay of 10% then you will have to pay 1% of the claim amount and the rest will be paid by the insurer.

One more thing, if your group health insurance provider settles the whole claim amount then you cannot reach out to your personal health insurance provider but if the group health plan provider settles a part of the claim then you can get the remaining amount settled through your personal insurer.

Conclusion

Providing group health insurance to your employees reflects that you care about them and eventually reflects in their work. But it is also important to make sure that the insurance company you have opted for to purchase the group health plan provides a seamless claiming process. However, it is recommended to purchase a group health plan from an insurance company that has a large number of network hospitals tied up with them so that you can get cashless claims but it is also recommended to learn about your insurer by doing online research about their history of claim settlement through reimbursement.