Health Insurance Claim Process: A Step-by-Step guide

When the request is sent, the insurer is informed to initiate the claim process. There are two main types of claim options: cashless claims and reimbursement claims. Let us have a look at both of them.

Cashless Claims

Under the Group Health Insurance plan, if an employee files an insurance claim and selects a cashless claim, there is no need to worry about making the payment towards the hospital bills. It means the medical bills related to the admission and treatment of employees or their family members are settled between the hospital and the insurer. Also, in some cases, third-party administrators (TPA) are involved in smoothening the claim processes.

Steps of Cashless Claim Process:

• Look for the nearest hospital which considers cashless claims.
• Inform the insurance provider or TPA about the admission. In case of pre-planned treatments, you should inform 48 hours before the admission, and in case of emergencies, inform within 48 hours.
• You should present the policy health card to the employer or TPA of the hospital chosen.
• Fill out the group health insurance claim form available at the hospital to submit all the details asked.
• The claim form is then shared with the insurance provider by the hospital to get the claim approved.
• The claim would be reviewed by the insurer for either rejection or approval.
• After the claim is approved and the treatment is over, the hospital bills will be shared with the insurer for settlement purposes.

Reimbursement Claims

• Here, in this claim type, the hospital bills are initially cleared by the insured employee, and then they can get the claim reimbursed once the documents and proofs are submitted. 
• Initially, the hospitalisation and medical expenses have to be paid by the employee himself and then reimbursed by raising the claim.

Steps of Reimbursement Claim Process:

• Inform the insurer or Third party Administrator about the treatment within 24 to 48 hours of hospitalisation.
• After filing the insurance claim, a claim number will be generated. Collect the same for your reference to claim the tracking status.
• Visit any hospital to get the treatment done. Also, fill out the group health insurance claim form provided by the hospital.
• Collect all the hospitalisation and medication bills, invoices or receipts.
• Submit the insurance claim form along with the required documents to the insurer or TPA.
• After reviewing, the insurer can ask for further documentation or information, if required, before the claim reimbursement amount gets approved.
• After approval, the amount will be reimbursed to the bank account.

Conclusion

Understanding the different kinds of group health insurance claim processes makes both employers and employees informed and prepared. By getting familiarised, one can take proactive steps, which will help save time, stress and confusion when the need arises.

(This article is part of DMCL Consumer Connect Initiative, a paid publication programme. DMCL claims no editorial involvement and assumes no responsibility, liability or claims for any errors or omissions in the content of the article. The DMCL Editorial team is not responsible for this content.)