How do I claim a group health insurance?

Group health insurance claims https://www.ethika.co.in/group-health-insurance/ can be made either through cashless mode or reimbursement mode. In case of cashless mode, the claim can be made only in the network hospitals where the cashless claim settlement facility is available. 

 

In case of treatment availed from non-cashless hospital the claim can be availed on reimbursement basis where the customer has to pay the bill first and submit the documents to avail the claim. 

Cashless: In case of cashless the claim amount would be paid by the insurance company to the treating hospital directly without the involvement of the customer to pay the bill. The company would settle the claim up to the limits mentioned under the policy and the remaining amount has to be borne by the insured customer. 

Step 1: In the first step you should visit the hospital where you are planning to avail treatment and confirm with them the cashless availability or the same can be confirmed from the insurance company’s website. If the cashless facility is available then you should submit your cashless health card with the duly filled cashless claim settlement form. 

Step 2: Then the form would be processed by the insurance company and the necessary approvals would be given to the hospital to proceed with the cashless facility. 

Step 3: The hospital would proceed with the treatment and let you know if any amount has to be paid by you which does not come under the liability of the insurance company. This amount has to be settled before discharge. 

Step 4: The last step is the discharge of the customer from the hospital after clearing the bills. It is advisable to inform the insurance company 24 -48 hours prior in case of planned cashless hospitalization and within 24 hours in case of emergency hospitalization.

Reimbursement: The other process is reimbursement where you have to pay the bill first and then claim it from the insurance company which is explained below. 

Step 1: The reimbursement process is available when you avail the treatment by paying the bill and later claim it from the insurance company. In case of reimbursement, an intimation should be given to the insurance company within 24-48 hours and the claim should be lodged with the insurance company. Once the claim is intimated the insurance company would generate a claim intimation number which can be used to quote in future communications. After availing the treatment all the original bills should be collected from the hospital. 

Step 2: Then the duly filled claim form along with all the original hospital bills and canceled cheque leaf should be submitted to the insurance company for processing the claim. If the complete set of documents are not received then the claim settlement would be delayed. It is important to send all the required documents at once so that there would be no delay in claim settlement. After submission of the documents the claim would be reimbursed within 15 working days depending on the insurance company.