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Insurance & Claims

Manage group insurance (medical, life) and process the claims employees file against it. Employees submit claims from self-service; HR reviews each one and drives it through to settlement with the provider.

Screenshot: Insurance claims admin dashboard — TODO

Open HR Management → Insurance (/hr/insurance/claims).

Manage the group policy (HR)

Claims always bill against the corporate group policy that is active on the submission date, so set the policy up before employees can file. From the claims dashboard click Policies (/hr/insurance/policies):

  • New policy — policy number, provider, cover start/end dates (AD/BS picker), coverage plan (employee only … employee + spouse + children + parents) and the maximum coverage limit.
  • Renew — add the next year's policy with its new cover window. Two active policies can never have overlapping cover windows — deactivate the old one or adjust the dates.
  • Deactivate — stops new claims billing against the policy; existing claims are unaffected.

Employee files a claim (ESS)

From the Employee Self-Service portal (/ess/insurance/claims) an employee submits a claim with the nature of the claim, the amount, the patient/beneficiary, and supporting documents (PDF/JPG/PNG, up to 5 MB each). The original bills & receipts file is mandatory — the form won't submit without it. Files upload as soon as they're chosen; the claim then appears in the HR dashboard as a new claim.

Process a claim (HR)

The admin dashboard lists each claim with its Claim ID, Employee / Patient, Nature, Submitted On, Claimed (NPR), and System Status. The document icon on each row opens the employee's uploaded bills for review. Open a claim and choose an Action:

  • Forward to Insurance Provider — send it on for assessment (record the Provider Reference No. if you have one).
  • Request Additional Docs from Emp — bounce it back to the employee for more paperwork.
  • Mark as Settled (Funds Cleared) — close it once the payout has cleared.
  • Rejected by Provider — record a declined claim.

Each action updates the claim's status and notifies the employee, so they can follow progress from their claim list in self-service.

Keeps medical and payroll separate

Insurance claims are reimbursed by the provider — they are tracked here, not paid through payroll. Use Salary Advances for a medical advance that the employee repays.