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Group Health

Hospitalisation cover for employees and, where extended, their families, cashless at network hospitals and by reimbursement elsewhere.

Also calledGroup Mediclaim · GMC · Group Health Insurance

File/Claims library/People and employee benefits/Illness, hospital and life

First thing, todayFor a planned admission, get pre-authorisation before the date. For an emergency, intimate within the window the policy allows.

Three deadlines
  • Tell the insurer now, not after the assessment.
  • Pre-authorisation, or intimation before a planned admission, and within the hours the policy allows after an emergency one.
  • Every document within the time the insurer asks for it.
A card index pulled open at the staff records, one card set on top
A card index pulled open at the staff records, one card set on top. An illustration.

When you would claim

  • Employee or dependant admitted to hospital
  • A cashless request declined at the hospital desk
  • A reimbursement claim short-settled on deductions
  • A pre-existing condition question raised at claim stage

What insurers most often rely on

  • A waiting period not served on that condition
  • A treatment or a room category outside the policy limits
  • Non-payable items such as consumables and administrative charges
  • Late intimation of an emergency admission
  • A member added after the loss, or not on the declared list

Most of them turn on a record kept long before anybody was hurt, which is why the wage and attendance registers decide these claims.

The documents

from three places at once

9 items, arriving from a hospital, an employer and sometimes a police station, on three timetables that do not co-operate. Start all three on the same day.

  • Claim form signed by the employee and the hospital
  • Pre-authorisation request and the TPA's response
  • Discharge summary and the final hospital bill, itemised
  • All investigation reports and prescriptions
  • Payment receipts and the pharmacy bills
  • Employee identity and the policy or e-card
  • Bank details for reimbursement
  • Details of any other insurance covering the same risk
  • The amount claimed after whatever the hospital has already deducted, with the reason given for each deduction
Two clocks, not oneThere is the policy's clock and there is the statute's, and they run at different speeds. Keep one page with both on it: what was reported to the insurer, and what was filed where the law required.

Next

What the first day looks like

There is no playbook for this and there will not be one, because the first day is short. Tell the insurer or the TPA inside the hours the policy allows, keep every original the hospital gives you, and do not let a discharge happen before the pre-authorisation query has been answered in writing.

Call 92514 56334

Read the sub-limits

The sum insured is rarely what decides a health claim. The room-rent cap is, because exceeding it proportions the whole bill and not only the room; and after that the disease-wise sub-limits, the co-pay and the list of non-payables do the rest.

Filed under: People and employee benefits · Illness, hospital and life

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Hospital bill cut, or a policy nobody will explain to you? Report a loss or call 92514 56334.