What is GIPSA & How Does it Work?

GIPSA, also known as the General Insurance Public Sector Association, is a group of four general insurance companies. The group includes National Insurance Co Ltd., Oriental Insurance Co Ltd., New India Assurance Company Ltd., and United India Insurance Co Ltd.

The GIPSA was founded to standardise the cost of treating common ailments. Under GIPSA, the companies involved pool resources and align strategies to make the claim process smoother and consistent for the policyholder.

The system also helps negotiate uniform rates for common medical procedures, providing affordability to policyholders across the country.

The role of GIPSA in group health insurance is to create a streamlined system in which the empanelled hospital and public sector insurer collaborate easily. Here are reasons why the GIPSA package is popular in health insurance.

• Cost consistency: Medical expenses can vary widely from one hospital to another, making it difficult for policyholders to plan their treatment costs. GIPSA helps reduce this uncertainty by finalising standard treatment rates with empanelled hospitals.

• Faster cashless claims: GIPSA streamlines claim processes, resulting in quicker approvals and smoother settlements for policyholders.

• Focus on quality treatment: Hospitals that are part of GIPSA agreements are expected to provide quality medical care while adhering to pre-agreed treatment costs.

The GIPSA insurance package is designed to keep hospital treatment costs standardised and make the claims process smoother for policyholders. Here’s how it works:

Step 1: Policy Purchase

The process begins when an individual or an organisation purchases a group health insurance plan from an insurer that follows GIPSA guidelines. These policies are commonly offered to employees as part of a group health insurance benefit. Once the policy is active, policyholders are eligible to avail medical benefits.

Step 2: Accessing PPN Networks

In the event of planned treatment or a medical emergency, the policyholder can choose a hospital from the PPN (Preferred Provider Network). These hospitals have agreed to provide medical treatment at pre-negotiated, standardised package rates.

Selecting a PPN hospital helps minimise unexpected medical expenses and ensures greater cost transparency at the time of admission.

Step 3: Cashless Facility

At a PPN hospital, the policyholder can apply for a cashless hospitalisation facility. The hospital coordinates directly with the insurer or third-party administrator (TPA) for approval.

Since treatment costs are already standardised under GIPSA, the approval process is usually quicker, allowing the policyholder to focus on recovery rather than paperwork or payments.

Step 4: Reimbursement (Non-PPN)

If the policyholder chooses a non-PPN hospital, treatment can still be availed, but the claim is settled on a reimbursement basis. In such cases, the policyholder pays the hospital bills upfront and later submits the required documents to the insurer.

The claim amount is assessed based on GIPSA package rates, which may result in partial reimbursement if hospital charges exceed the standard rates.

Step 5: Claim Management

Once the claim is submitted, the insurer evaluates it in accordance with the policy terms and GIPSA guidelines. Proper documentation and adherence to package rates help ensure faster claim settlement.

The structured approach followed under GIPSA reduces disputes, controls inflated billing, and brings consistency to the overall claim management process.

The GIPSA package offers standardised rates for different medical and surgical procedures. These medical procedures can be minor, critical, etc. Let us have a look at different eligible medical procedures.

• Cataract surgery

• Appendicitis

• Dialysis

• Kidney stone

• Angioplasty

• Organ transplant

• Hip and knee replacement

• Hysterectomy

• Hernia repair

• Cancer treatment

These are some of the medical procedures covered under the GIPSA package.

Here are some of the crucial benefits of the GIPSA package:

• GIPSA companies encourage cooperation and coordination in the insurance sector. It helps the member organisations work effectively and efficiently by sharing information, resources, and knowledge.

• GIPSA works to provide standard packages and charges for specific medical procedures, helping customers avoid overcharging and ensuring better utilisation of the sum insured.

• It acts as the representative of its members and engages with industry stakeholders and authorities to advocate for favourable policies and regulations.

• GIPSA works to develop its members' skills and knowledge through skill-development workshops, seminars, training, and teachings. It also enhances professionals' cultural development.

• It takes initiatives in infrastructure, technology adoption, and related areas that can help the member reduce costs and improve profits.

• GIPSA has a vast network of hospitals, and medical procedures such as liver and kidney transplants, CABG, and dialysis are usually covered by them.

Apart from its benefits, the GIPSA package also has certain limitations and challenges. Some of these limitations are:

• Limited Cashless Network: One of the main challenges policyholders face while availing the GIPSA package is the limited cashless network. The hospitals within the GIPSA-approved frameworks are mostly in rural and Tier-3 cities.

• Handling Emergencies: The GIPSA-approved PPN hospitals are generally suitable for planned medical procedures. However, when it comes to handling medical emergencies, the procedure and paperwork can be a little bit tricky.

• Potential for High Deductions (Non-PPN): The GIPSA standard rate applies to PPN hospitals; applying the same procedure in Non-PPN can result in high deductions. Non-PPN hospitals generally apply prevailing rates based on geographic location, which can lead to unnecessary deductions at the time of reimbursement.

• Information Gaps and Misconceptions: Another challenge policyholders may face when dealing with GIPSA packages is the presence of information gaps. Most policyholders often lack information about coverage, network availability, and deductibles.

• Administrative Burden: Lastly, non-profit organisations and employers with a limited workforce can find GIPSA complex. Managing the compliance and claims process can be overwhelming, especially with limited HR resources.

A GIPSA network means the standardised health coverage and agreed treatment rates negotiated by the GIPSA companies and empanelled hospitals. While this structure helps control costs and simplifies claims, many policyholders are not fully aware of how the package works. To help out, here are some key things to keep in mind.

Availing PPN Hospitals Only

One key thing to keep in mind when using the GIPSA insurance package is to use PPN hospitals only for cashless treatment. You need to check whether the hospital is part of the GIPSA before availing any planned or emergency treatment. You can easily check this by assessing your policy documents.

Fulfilling Pre-authorisation Requirements

Another thing to keep in mind while availing the GIPSA package is fulfilling the pre-authorisation requirements. For any planned hospitalisation, you need to obtain pre-authorisation from your insurance provider and the TPA. This will help ensure that the procedure or treatment you will undergo is covered under the GIPSA package.

Adhere to Fixed Rates

GIPSA packages provide pre-negotiated, fixed treatment rates agreed upon by PPN hospitals. Policyholders should ensure that hospital bills align with these standardised rates. Any additional services, upgrades, or non-medical expenses not included in the package may need to be paid out of pocket.

Know the Inclusion and Exclusion

Not all treatments, procedures, or hospital services are covered under a GIPSA package. It is important to clearly understand what is included and excluded, including room rent limits, specific procedures, consumables, and diagnostic tests. Knowing these details in advance helps policyholders plan better and avoid unexpected expenses during or after hospitalisation.

Reimbursement Outside PPN

Another important point to keep in mind is how reimbursement works when treatment is taken at a non-PPN hospital. In such cases, policyholders are required to pay the hospital bills upfront and later submit a reimbursement claim to the insurer.

The claim amount is assessed based on GIPSA package rates, which means expenses exceeding the standard rates may not be fully reimbursed. Being aware of this helps policyholders make informed hospital choices and better manage out-of-pocket costs.

Claim settlement procedures under the General Insurance Public Sector Association are easy. Policyholders can avail the cashless and reimbursement claims. Let us understand both procedures in detail.

Cashless Claim Procedure

The cashless treatment in the GIPSA package can be availed at the PPN network hospital. Here is how to avail the treatment.

• Notify the Insurer and TPA: To begin the treatment, notify the insurance provider about the planned or emergency hospitalisation within the timeframe. This is generally 24 hours after emergency hospitalisation and 48 hours before planned hospitalisation.

• Submit Documents: Visit the empanelled PPN hospital and submit your insurance policy documents at the hospital desk. These documents include insurance policy numbers, cards, ID proofs, and more.

• Pre-authorisation: After all documents are received, the hospital will submit the pre-authorisation request to the insurance provider.

• Verification and Approval: The insurance provider will review the details and, if everything appears to be in order, send approval for cashless treatment. The hospital will begin treatment in accordance with the GIPSA package rates.

Reimbursement Claim Procedure

If the policyholder is receiving treatment at a Non-PPN hospital or the cashless is rejected, you can avail of the reimbursement facility. Here are the steps you need to follow while seeking reimbursement for treatment.

• Notify the Insurance Provider: To avail of the reimbursement, inform the insurance provider of the hospitalisation within the agreed timeframe.

• Settle Medical Bills: Then, visit the hospital of your choice and receive treatment. Once treatment is done, you need to pay the medical bills by yourself.

• Collect Documents: After paying the medical bills, promptly collect all documents from the hospital. The documents include medical bills, discharge summary, diagnostic report and more.

• Submit Claim Request: Once all required documents are in place, complete the claim form and submit it to the insurance provider, along with the other documents.

• Review and Settlement: The insurance provider will review the claim and then either approve or reject the request. If the claim has been approved, the insurance provider will settle the bills in accordance with the GIPSA standard rates. Policyholders might need to pay the deductibles out of their own pocket.

Here is the list of documents you need to submit for claim settlement under the GIPSA package.

• Duly filled and signed claim form

• Original hospital bills

• Discharge summary

• Prescription report

• Doctor’s diagnostic report

• Valid ID proof

• Address proof

• Any additional documents required by the insurer

Knowing what GIPSA is crucial for individuals looking for standardised medical rates and a streamlined claim process. With the GIPSA package in place, policyholders will get quality medical treatment at affordable rates. It is also helpful for businesses seeking corporate health insurance to support better cost control and smoother employee claim experiences.

When it comes to affordable group health insurance for employees, TATA AIG offers customised plans based on your business needs. Our group insurance plans cover a range of medical services, including hospital stays, daycare treatments, maternity care, and surgeries.

Along with this, our commercial insurance policy, like group health plans, offers benefits such as hassle-free claims processing, minimal documentation, quick policy issuance, and more. With this in mind, protect your employees with our tailored group insurance plans.