AI Tool ClaimSetu Launched To Speed Up Group Health Insurance Reimbursement Claims

Reimbursement claims under group health insurance (GHI) have often been a pain point for corporate policyholders, riddled with delayed or paper heavy claims processes. Policybazaar for business has now launched a new artificial intelligence powered solution which aims to rewire how GHI reimbursement claims are processed in India.

With a focus on making the system faster, more transparent, and less error-prone, it is being seen as the country’s first AI-led claims engine for enterprise health insurance workflows.

Unlike cashless claims, where the hospital and insurer settle the bill directly, reimbursement claims typically require employees to compile documents, send emails, follow up with TPAs, and wait in the dark. ClaimSetu is designed in a way to ease every step in that journey.

How will this tool work?

ClaimSetu uses artificial intelligence to read and process documents like patients discharge summaries, hospital bills, prescriptions, and pharmacy invoices to process the claims.

It is designed in a way to flag missing or mismatched documents and check for any inconsistencies against the policy terms.

Users, who could be employees, HR teams, or insurers, are kept in the loop as the tool sends out instant alerts and live updates through WhatsApp or email.

This tool further has capability to read as well as ‘score’ claims based on the likelihood of them getting approved and routes the same based on its complexity by suggesting next steps the users take.

According to PBFB, the result is up to 50 per cent faster claim settlements and a dramatic reduction in manual back-and-forth.

“Reimbursement claims remain one of the most tedious aspects of group health insurance,” said Sajja Praveen Chowdary, Director at PBFB.

“We’re addressing the highest-friction area first, and trying to remove the ambiguity that’s usually baked into the process.”

For now, the focus of this tool is on reimbursement claims under GHI policies, but it is structured to expand into other segments such as OPD claims without requiring a complete rebuild.