Claiming Under a Group Insurance Policy

Group insurance — whether a group health plan through your employer or a group life cover through a credit institution or association — works differently from individual policies. The master policyholder (usually the employer or institution) manages the policy, which changes how claims are filed, tracked, and settled. Here is what you need to know as a member or beneficiary.

How Group Insurance Works

In a group policy, the insurer contracts with the master policyholder (employer, bank, association). Each member is covered as a certificate holder, not as a direct policyholder. The master policyholder receives the master policy; members receive a certificate of insurance or an employee identity card. Your HR or group administrator is your first point of contact — not the insurer directly.

Group Health Insurance: Cashless Claims

Step 1: For planned hospitalisation, inform your HR or the TPA (whose contact details are on your health card) at least 72 hours in advance. For emergencies, inform within 24 hours.

Step 2: At the network hospital, present your corporate health card and employee ID. The hospital''s insurance desk will initiate the pre-authorisation request with the TPA on your behalf.

Step 3: The TPA approves, queries, or rejects the pre-auth. Follow up through the HR/TPA helpline if there is a delay beyond 4 hours.

Step 4: At discharge, pay only the non-covered amounts (typically registration, consumables, charges above room rent limit).

Group Health Insurance: Reimbursement Claims

If admitted at a non-network hospital, collect all original bills and documents at discharge and submit a reimbursement claim through your HR within the stipulated window (usually 30 days). The HR submits to the insurer/TPA on your behalf.

Group Life Insurance: Death Claim

The nominee files the claim through the employer''s HR department, not directly with the insurer. Required documents include:

• Death certificate
• Certificate of employment confirming cover at the time of death
• Nominee''s KYC and NEFT details
• Claim form (HR will provide)
• For accidental death: FIR and post-mortem report

Limitations of Group Cover

• Cover ends when employment or membership ends — no continuity guaranteed
• Sum assured may be a multiple of salary, not individually chosen
• Benefits may be reduced or discontinued by the employer at renewal

Porting Group Health to an Individual Policy

IRDAI allows you to port your group health cover to an individual policy upon leaving employment, preserving your waiting period credits. Apply within 30 days of policy expiry and declare your group cover history.

Conclusion

Group insurance is a valuable benefit but should be complemented with individual cover to avoid gaps. If you are changing jobs or want to evaluate whether your group cover is sufficient, TruePolicy can help you assess the gaps and find individual policies that provide the continuity your group plan cannot.