Claims Management in Group Health Insurance

Health emergencies are quite unpredictable and managing medical expenses can be overwhelming without the right financial support. This is where group health insurance plays a significant role in easing the burden off the employees and providing adequate medical coverage.

However, merely having the policy is not enough, it is essential to understand the claim management in group health insurance policy and make the most out of its benefits. From cashless and reimbursement claims to the application process, in this blog, we will explore everything you need to know about claim management healthcare.

Understanding Group Health Insurance Policy

Group health insurance is a type of insurance that provides medical coverage to a large group of people that usually comprises employees of the company or members of the organisation. Such insurance policy offers collective coverages and benefits, such as hospitalisation costs, medical bills, and diagnostic reports, to all the members of the insured group.

Group health insurance policies play a vital role in securing the financial security of employees and providing access to quality healthcare. And while the premium payments are either solely made by the employer or are partially contributed by the employees, make it an affordable option among various health insurance plans.

Types of Claim Management in Group Health Insurance

Claim management in group health insurance policy can be categorised into two types based on the purpose they serve:

Cashless Claims Management

Cashless claims allow the insured member to receive medical treatments at a wide range of networks of hospitals without paying any upfront payment, and the hospital directly settles the medical bill with your insurance provider. Cashless claims management helps members avoid out-of-pocket expenses, eliminating their financial strain and ensuring a quick and hassle-free process.

How does it work?

• The policyholder must choose a hospital for their treatment from the insurance provider’s network of hospitals.
• The hospital will then submit a pre-authorisation request to the concerned insurance company.
• Once approved, the policyholder can receive the medical treatment from the hospital without paying any upfront fees and the insurer will settle the bill with the hospital in accordance with the coverage limits.

Documents Required

There are various documents required to process the cashless claims, such as:

• Government identification card, like Adahaar Card, PAN Card, or Voter ID Card
• Employee group health insurance card
• Duly-filled medical claim form
• Proof of admission into the hospital
• Bank statement of the the policyholder

Reimbursement Claims Management

Reimbursement claims are helpful when the insured member pays the medical expenses of the treatment on their own and later seeks reimbursement from the insurance company. This method is usually useful in case of medical treatment from a non-network hospital or if the cashless claim is denied.

How does it work?

• The policyholder pays for medical treatment upfront.
• After the treatment, collect all the necessary documents, such as medical bills, diagnostic reports, hospitalisation bills, etc. and submit them to the insurance company.
• The insurance company will review the claim request.
• If approved, the insurer will process the claim amount to the insurer’s bank account as per the coverage benefits of the policy. 

Documents Required

• Duly-filled medical claim form
• Employee group health insurance card
• Certificate from an authorised doctor
• Relevant medical reports and prescriptions 
• Proof of hospital bills, medication costs, diagnostic reports, etc. 
• Hospital discharge card

Application Process of Claims Management

Whether you are opting for a cashless or reimbursement claim, it is important to know the application process of claim management healthcare. Here is the step-by-step guide to filing a claim form:

Step 1 - Inform the Insurance Provider

Notify the insurance provider as early as possible about the hospitalisation

Step 2 - Get Pre Authorisation (in case of cashless claims)

Submit the necessary documents to get pre-authorisation and avoid any out-of-pocket expenses.

Step 3 - Collect Required Documents (in case of reimbursement claims)

Collect all the necessary documents, such as hospital bills, pharmacy bills, diagnosis reports, prescriptions, and doctor’s authorisation.

Step 4 - Submit the Claim Form

Fill out and submit the claim form along with all the necessary documents to the insurance company.

Step 5 - Follow Up

Keep track of the claim request through the insurer's website or its customer service.

Step 6 - Claim Settlement

Once approved, the hospital bills will be settled, in case of cashless claims, or insured amount will be processed in your bank account, in case of reimbursement claims.

Read More : E-Claims in Group Health Insurance: A Comprehensive Guide

Final Words

Understanding the claim management of group health insurance enables employees to get the most out of their insurance benefits and stay stress free. Health emergencies are uncertain but with the right insurance plan and familiarity with the claim application process can make the experience smooth and keep your peace of mind, whether you are opting for cashless or reimbursement claims.

Moreover, employers that offer group health insurance should educate their employees about the insurance benefits and its claim process to ensure a healthy and positive workforce that consequently drives the business growth. And if you are looking to provide comprehensive health insurance to your employees and create a thriving work environment, check out well-curated insurance plans today.

FAQs

1. What is claim management in health insurance?

   Claim management in health insurance refers to the process of applying for and getting claims for policyholders medical treatment as per the insurance coverage limits.

2. How to claim group insurance?

   The policyholder can file for a claim in group insurance by submitting a form along with all the necessary documents.

3. What are the two major types of claims?

   The two major types of claims are cashless claims, which are permissible in a network hospital of the insurer without paying the upfront fee, and reimbursement claims, which require you to pay the medical fees and later claim for reimbursement.