What role does an insurance broker play in claims support after purchase?

An insurance broker's role does not end at policy placement. Post-purchase, the broker acts as the employee's advocate in the claims process, interpreting policy terms, escalating cashless denials with the TPA, tracking claim status, and coordinating grievance escalations where needed. This ongoing support is what distinguishes a broker relationship from a direct-to-insurer purchase, where employees deal alone with the TPA on every issue.

What does a broker do when an employee needs to file a claim?

The broker typically provides four types of support at claim time:

• Policy interpretation: Confirming which policy terms apply to the specific claim, including sub-limits, co-payments, and waiting periods.
• Documentation guidance: Walking the employee through required documents for cashless or reimbursement, so submissions are complete on the first attempt.
• TPA coordination: Following up with the TPA on approval status, especially when the IRDAI-mandated 1-hour cashless timeline or 3-hour discharge timeline is at risk.
• Escalation: Taking cases to the insurer's grievance officer, Bima Bharosa, or the Insurance Ombudsman where the TPA or insurer response is inadequate.

Is the broker's claims support different for cashless and reimbursement?

Yes. For cashless claims, the broker's support is time-sensitive and often happens in real time during hospitalisation, coordinating between the hospital's insurance desk, the TPA, and the family. For reimbursement claims, the support is documentation-heavy, ensuring the employee submits a complete claim within the policy's time window and that any deficiencies flagged by the insurer are addressed promptly.

What happens when a cashless request is denied?

The broker steps in as the primary escalation channel. The workflow typically involves getting the written denial from the TPA, reviewing whether the denial reason holds against the policy terms, requesting reconsideration with additional medical documentation from the treating doctor, and escalating to the insurer's grievance officer if the TPA does not reverse the decision. Where the denial is procedural rather than substantive, the broker's intervention often reverses it within hours.

Does a broker help with reimbursement claim tracking?

Yes. Reimbursement claims can take up to 30 days under IRDAI's Master Circular on Health Insurance Business dated 29 May 2024, and employees often lose track of status mid-way. The broker maintains a claims log, follows up with the TPA at defined intervals, and alerts the employee to any missing documents the insurer has flagged. Where the insurer breaches the 30-day timeline, the broker pushes for interest at 2% above the bank rate on the delayed settlement.

What reporting does a broker provide to HR?

A capable broker shares monthly or quarterly reports covering total claims filed, claims approved and denied, average cashless approval time, claim rejection reasons, and utilisation by demographic (employee vs family vs parental). This reporting helps HR spot patterns (recurring denials at a specific hospital, high rejection rates for a particular procedure) and address them at policy level rather than case by case.

Can employees contact the broker directly?

Yes, at most broker arrangements. Employees are given a broker helpdesk number, email, or portal at policy onboarding, and can contact the broker directly for any claim-related issue rather than routing everything through HR. This reduces HR administrative load and speeds up employee support.

How Plum approaches this

Plum operates a dedicated claims team that employees can contact directly, in addition to HR-side reporting for employers. Across Plum's group book, claims NPS runs at 79 and cashless pre-authorisation clears in a median of 45 minutes, both driven by active broker intervention on the TPA side rather than a hands-off broker model. Plum places group cover from a minimum of 7 employees, working with partner insurers including ICICI Lombard, HDFC ERGO, Bajaj Allianz, Star Health, Niva Bupa, and Aditya Birla Health Insurance, and applies consistent claims support standards across all partner TPAs.

Frequently asked questions

Is broker claims support included in the premium?

Yes. Broker commission is paid by the insurer as part of the premium, so employees and HR do not pay separately for claims support.

Can the broker override an insurer's claim decision?

No. Only the insurer or the Insurance Ombudsman can reverse a claim decision. The broker's role is to advocate for reconsideration with strong documentation.

What is the broker's role in the Insurance Ombudsman process?

The broker helps prepare the complaint, files it through Bima Bharosa if the insurer's response is inadequate, and represents the employee's case during the Ombudsman review.

Does the broker interact with the hospital directly?

Yes, particularly for cashless coordination. The broker often calls the hospital's insurance desk to speed up submission or resolve documentation gaps.

How is the broker held accountable?

IRDAI licenses brokers under the IRDAI (Insurance Brokers) Regulations, 2018, and brokers are answerable for service quality to both the policyholder and the regulator.

Can HR see the same claims data that the broker sees?

Yes. Most brokers share claims dashboards with HR, though individual employee identities are protected in aggregated reporting.