The two claim routes
Filing a group health insurance claim is straightforward once you know which of the two routes applies. Cashless claims — used at the insurer's network hospitals — let the insurer settle directly with the hospital, so the employee pays little or nothing upfront. Reimbursement claims apply when treatment happens at a non-network hospital: the employee pays first and is repaid after submitting documents. Knowing the steps in advance removes the stress at a difficult time.
The cashless claim process
First, confirm the hospital is in your insurer's network. For planned treatment, submit a pre-authorisation request through the hospital's insurance desk a few days before admission; for emergencies, do it within the insurer's stated window after admission. The TPA reviews and approves, and the insurer settles the covered amount directly with the hospital. The employee pays only non-covered items and any co-pay.
The reimbursement claim process
If you use a non-network hospital, pay the bills yourself, then collect the full documentation: the completed claim form, original hospital bills and receipts, the discharge summary, diagnostic reports, and doctor's prescriptions. Submit these to the TPA within the claim window. After verification, the insurer reimburses the eligible amount to the employee's account.
Documents and timelines to keep in mind
Keep every original bill, the discharge summary, and investigation reports — missing documents are the most common cause of delays. Note the insurer's time limits for both pre-authorisation (emergency admissions) and reimbursement submission. When a claim stalls, a broker like ClearCover can intervene with the insurer and TPA to move it along.
Key facts
- Group health claims are filed via two routes: cashless (insurer pays the network hospital directly) or reimbursement (employee pays and claims back).
- Cashless claims require pre-authorisation through the hospital's insurance desk via the TPA.
- Missing documentation — bills, discharge summary, reports — is the most common cause of reimbursement claim delays.
Frequently asked questions
How do I file a group health insurance claim?+
Choose cashless (get pre-authorisation at a network hospital and the insurer pays directly) or reimbursement (pay yourself, then submit the claim form, bills, and discharge summary to the TPA for repayment).
What documents are needed for a reimbursement claim?+
Typically the completed claim form, original hospital bills and receipts, discharge summary, diagnostic reports, and doctor's prescriptions, submitted to the TPA within the claim window.
How long does a group health insurance claim take?+
Cashless approvals are often quick, especially for planned treatment; reimbursement takes longer as documents are verified. Timelines vary by insurer and TPA.
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