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

Also known as Group Mediclaim Insurance or Corporate Medical Insurance, this policy provides financial coverage to a group of individuals, generally a company’s employees or an organisation’s members.

It can also be extended to the insured employee’s family members, including children, spouse and even dependent parents.

The objective of a group mediclaim insurance policy for employees is to ensure that the insured employees are financially protected against medical charges resulting from hospitalisation, injury or illness. This way, it makes expensive medical bills affordable to the employees and their family.

The claim process for most health policies in India is more or less the same. Most of these group mediclaim policies offer two types of options for claims including reimbursement and cashless claims.

Here is how you can claim a group mediclaim policy for each option:**

For Reimbursement Claim:

Step 1: Notify the insurer as soon as possible once the insured individual is hospitalised. You can either contact the customer support service or email the insurer to receive a claim number.

Step 2: Collect all the bills paid to the hospital, ensuring that the hospital authority signs and stamps on each bill. Additionally, make a copy of all the treatment records, such as vital charts and treatment charts and assemble them.

Step 3: Submit these copies to the insurer’s official address for correspondence and wait.

Step 4: The insurer will review the documents and bills and, if necessary, ask you for additional documents.

Step 5: Once all the documents have been received and processed, the claim amount will be reimbursed to you, subject to the policy terms. However, any discrepancy will result in either delay or rejection of the claim.

For Cashless Claim:

Step 1: Visit the nearest hospital authorised by your insurer for cashless medical treatment.

Step 2: Notify the Third-Party Administrator (TPA) or insurer as soon as the hospitalisation process is initiated.

Step 3- The document that the insurer provided the insured individual, citing the details of the mediclaim policy for the family must be submitted at the selected hospital.

Step 4- The group mediclaim policy form that the hospital provides has to be filled out and submitted.

Step 5- After the hospital has received this claim form, they will share it with your insurer for claim approval.

Step 6- The form will be reviewed by the insurer and will either be rejected or approved.

Step 7- If approved, treatment will be provided and the hospital bills will be settled by the insurer.

No Medical Assessment Required: The best family health insurance plans do not require medical check-ups of individual employees. This simplifies the process of enrolling employees, and makes it more convenient for employers to ensure that their employees enjoy the benefit of this health coverage.

Cost-effective Insurance Plan: A group active health plan generally provides coverage at a lower cost than other health plans. The affordability of this policy attracts employers to provide their workforce with health benefits.

Scope for Customisation: Often, employers are provided with the customisation option to make the plan flexible according to their employees' needs. This policy offers some options for customising insured members, day care procedures, pre- and post-hospitalisation costs and mid-term dependent addition.

Cashless Mediclaim Policy for Family: Several group mediclaim policies provide facilities for cashless hospitalisations. In this, insured individuals can visit hospitals authorised by the insurer to avail of medical treatment without needing to make upfront payments to the hospital.

Dependent Coverage Option: It is also possible to extend the group insurance mediclaim coverage to the dependent members of the employees’ families. This coverage may be provided to dependent children, spouses and dependent parents. This way, the entire family of insured employees can receive medical benefits.

While settling a claim under a group mediclaim insurance policy for employees is uncomplicated, the following tips will help you avoid claim rejection:**

No False Information: A common reason for the rejection of claims is the insured’s submission of false information. The insured employee must be transparent with their insurer regarding their age, medical conditions, lifestyle habits, etc. If they provide misleading information, they will face difficulty while settling their claim.

Disclose Pre-existing Medical Conditions: It is imperative that you share your pre-existing medical conditions at the time of filing your corporate medical insurance form. Whether you suffer from a cardiovascular disease, or diabetes or any other chronic ailments, or have previously undergone a surgery, etc., you have to inform your insurer.

Avoid Submitting Incorrect Documents: For obvious reasons, you cannot make a mistake while submitting your documents. All the bills and treatment-related documents must reach the insurer, or else your claim will be subject to rejection.

Ensure Timely Information: Most group active health plans require you to inform the insurer of pre-planned hospitalisations at least 48 hours before hospitalisation. In case of medical emergencies, you must inform your insurer within the first 48 hours of hospitalisation. If you fail to inform the insurance company on time, your claim can either be delayed or altogether rejected.

Learn about Exclusions: Insurance companies generally list out conditions under which coverage will not be provided to insured employees. General coverage exclusions include hospitalisation due to alcohol consumption or suicide attempts, etc. Therefore, you must check the policy documents carefully to understand its coverage scope.

Check for Policy Expiry: If you file for a claim after the policy has expired, it can lead to claim rejection.

The importance of corporate medical insurance for employees cannot be undermined in today’s unpredictable health scenario. However, without proper knowledge of filing a claim under the group mediclaim insurance policy for employees, it becomes pointless to own such a policy.

At Tata AIG, we ensure that your employees get financial relief during medical emergencies through smooth claim settlements. Moreover, we provide a claim tracking option to keep the claim process transparent and simple.

Explore our website to learn more about our affordable and customisable business insurance in India.

Who pays the premium for the group mediclaim policy?

The employer of the company is responsible for paying the premium for the group mediclaim policy. The employees are provided with the financial benefits of this policy. However, in some cases, the employer and the employees share the policy premium.

Can the insured employee personalise corporate medical insurance?

Generally, the employers customise a group mediclaim insurance policy for employees according to the requirements of their employees.