Smooth Claim Settlement

6 Strategies to Ensure Your Employees Have a Smooth Claim Settlement

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A smooth claim settlement process is an essential requirement for group health insurance policies. If the employees covered under a group health insurance policy face problems at the time of making claims, the whole purpose of group health insurance is defeated.

In order to ensure a smooth claim settlement process for the employees, the employer should consider the strategies listed here.

Ensuring Smooth Claim Settlement

Read Policy Documents Thoroughly

Reading the policy documents thoroughly is necessary to understand the features, clauses, and terms and conditions of the group health insurance policy purchased for the employees. The pre-requisites, such as documents required to file claims, must also be ascertained thoroughly from the policy documents.

In case of doubts or queries, clarification needs to be sought from the insurance agent or the insurance company. The details of the insurer’s grievance redressal mechanism in the event of problems in filing claims must also be known clearly. 

Overall, complete knowledge of the group health insurance policy is crucial to ensure smooth claim settlement.

Check Room Rent Capping

Room rent capping is a major cause of dissatisfaction among customers when filing claims. It is important to understand the concept of room rent capping in group health insurance to ensure smooth claim settlement for your employees.

Room rent is the amount charged by the hospital for the room in which the patient stays while getting treatment. It is charged on a per-day basis. Room rent capping refers to the limit to which the group health insurance policy would cover the room rent. The insured is liable to pay the additional amount if the limit is exceeded.

The room rent limit is usually 1-3% of the sum insured. The room rent limit can also be mentioned as a fixed amount on the policy document instead of a percentage of the sum insured. 

Room rent capping has a profound impact on the claims. The hospitals charge the patients for doctor’s visits, medicines, tests, and surgery on the basis of the types of rooms selected. For example, the charges linked to a room with a rent of Rs. 4000 would be more than a room with a rent of Rs. 2000. The insurer reduces the claim amount proportionately if the insured person exceeds the room rent limit. For example, if the policy has a room rent limit of Rs. 2000 but the insured gets admitted in a room with Rs. 4000, the insurer will pay only 50% of the total claim amount, not just the room rent.

Even if the difference in the costs of medicines, tests, and other treatment charges between various kinds of rooms in a hospital is marginal, the insurer has the right to reduce the claim amount in proportion to the extent of the room rent limit crossed. 

There are multiple solutions for room rent capping. You can choose a group health insurance policy with a high sum insured of Rs. 5 lakh or more because such policies do not carry room rent limits or opt for a policy with a higher sub-limit on room rent. Many group health insurance plans also offer room rent limit waivers. 

Understand the Exclusions and Co-Payments

A clear understanding of exclusions is necessary to ensure smooth claim settlement. Exclusions are certain medical conditions and treatment modalities that are not covered by the group health insurance policy. The insurer will deny any claim which falls under the exclusions mandated by the particular insurance policy. 

The list of exclusions is clearly mentioned in the policy document. It is important to go through this list thoroughly to avoid filing claims which are liable to be rejected. Common exclusions include alcohol and drug abuse, AIDS, attempt to suicide or self-harm, psychological disorders, congenital diseases, plastic surgery, gender-change surgery, fertility treatments, homeopathic and Unani treatment, dental treatments, and more.

It is important to ascertain whether a co-payment clause is present or not on the policy document to ensure smooth claim settlement. The co-payment clause means the insured must pay a certain fraction of the claim amount from their resources. The co-payment clause is usually written as 80-20, 70-30, 90-10, with the insurer’s contribution coming first, followed by the insured’s contribution. For example, under the 80-20 arrangement, the insured is required to pay 20% of the claim amount while the insurer covers the balance of 80%. Co-payment reduces the premium amount. If a co-payment clause is present on the group health insurance policy document, the employees cannot claim the whole amount spent on medical treatment.

Locate a Network Hospital

When it comes to smooth claim settlement, cashless claim settlement is the best method. Cashless claim settlement means the insurer settles the medical bill directly with the hospital where the insured has been treated. The insured is not required to pay anything. 

However, to avail of cashless claim settlement, it is necessary to get admitted to a network hospital of the insurer. Each health insurance provider has tie-ups with certain hospitals called network hospitals to provide cashless treatment facilities to its customers.

Thus, you should go through the list of network hospitals of your group health insurance provider and locate the ones present near you.

Keep the Identity Proof and Policy Document Handy

A smooth claim settlement process is ensured when all the required documents are in order. These include identity proof such as Aadhar/PAN/Passport/Voter ID/Driving License, policy documents, and proofs of treatment such as bills, receipts, test reports, discharge summary, and any other document specified by the insurer.

Understand the Claim Settlement Process

A clear understanding of the claim settlement process, such as whether to upload the documents digitally or handing over physically, required documents, and more helps in ensuring a smooth claim settlement.


By following the above-mentioned steps, you can ensure that your employees get a smooth claim settlement and there are no delays in claim processing.

To get the smoothest claim settlement experience make sure that you choose Vital by visiting


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