ShreeRaj Dusa/ Health benefits case study
Case study · Employee health benefits · 2026

Your company insured you. Nobody told you what that means.

Most employees in India get health cover through work, and learn what it pays for at a hospital billing desk. I designed an employee app and an HR dashboard that explain the cover in plain language, show the real cost before a hospital stay, and stop claims from bouncing back.

RoleProduct designer (solo)
PlatformsMobile app, HR web
ToolsFigma, FigJam, Claude
TypeSelf-initiated concept
CITY CARE HOSPITALFinal bill · Mr. R. Kumar · 3 days
Single room × 313,500
Surgery and theatre62,000
Medicines16,000
Doctor visits12,000
Total1,03,500
Insurance paid69,000
Room over limit−4,500
Proportionate deduction−30,000
You pay₹34,500
Surpriseat discharge
Try it: pick a room. The limit is ₹3,000 a day

An illustrative bill. The family chose a room ₹1,500 a day above their limit, and it cost them ₹34,500.

Short on time?

Watch the narrated walkthrough

The problem, the four app flows, the HR dashboard and how I’d measure success, narrated. Captions are on screen, so it also works muted.

The problem
Employees don’t know what their cover pays for until they’re at the hospital.

In one survey, 83% of employees didn’t know their employer’s health benefits, and 71% weren’t sure if their parents were covered.

See the evidence
What I designed
Cover you can understand in seconds, with costs shown in rupees.

Plain answers linked to the policy, the real cost of a room choice, claims checked before sending, and an HR view of stuck cases.

See the screens
How I’d judge it
No surprises at the hospital desk.

Claims accepted first time, final bills that match the estimate, and fewer benefits questions reaching HR. Not tested yet.

See the plan
01
The problem

A benefit people don’t understand until it costs them

Group health cover is growing fast in India, and companies offer more benefits every year. But employees get a policy PDF on day one, and the real questions only start when someone is admitted to hospital.

83%

of employees didn’t know the health benefits their employer offered. 71% weren’t sure if their parents were covered.

Onsurity survey, 1,150 employees, 2023 · Outlook Money
6 in 10

people who made a claim waited 6 to 48 hours for approval and discharge. The regulator’s limit is 3 hours.

LocalCircles · Moneylife
+41%

more health insurance complaints in FY25, reaching 1,37,361. Nearly 7 in 10 were about claims.

IRDAI annual report · Angel One
1 → 3

median health benefits per employer, up in four years. Group cover grows 23% a year. More benefits, more to explain.

Plum, State of Employee Benefits 2026 · MediaBrief
Hidden rule 1

Room rent limits cut the whole bill

Many policies cap room rent per day. Choose a room above the cap and the insurer doesn’t just skip the extra rent. It reduces many other charges by the same proportion, which most families only learn at discharge.

Twin · ₹3,000
₹0
Single · ₹4,500
₹34,500
Deluxe · ₹6,500
₹58,962

What the family pays on an illustrative 3-day stay with a ₹3,000 limit. Green: insurance. Clay: family.

Hidden rule 2

A 48-hour window for other hospitals

Since January 2024, insurers can offer cashless treatment at hospitals outside their list, if you tell them 48 hours before a planned admission, or within 48 hours of an emergency. Miss it, and you pay first and claim later.

Tell insurer
48 hours
Admission
Problem statement

Employees can’t tell what their company cover pays for, so they discover limits, deadlines and missing documents during a hospital stay.

02
People and moments

The employee uses the cover. HR is accountable for it.

Two people need different things at the same five moments. Tap a moment to see both sides. These personas come from secondary research and will be checked in interviews.

A

Ananya, employee

29 · Product analyst in Bengaluru · parents in Hyderabad
  • Added her parents at joining, but doesn’t know their limit
  • Handles hospital paperwork for family, often from another city
  • Wants to know, in rupees, what she’ll have to pay
M

Meera, HR

People Ops at a 400-person company · not an insurance expert
  • Answers benefits questions on Slack at all hours
  • Hears about stuck claims only when people escalate
  • Must protect employees’ medical privacy
03
The employee app

Four questions people actually ask, answered on one screen each

I started from what employees ask HR, not from the policy document. Scroll through the four flows; the phone follows along, and every screen can be tapped.

Flow 1 of 4

“Is Dad’s surgery covered?”

Plain answers, with the clause behind them

Employees ask about situations, not policy terms. Each answer starts with Yes, Partly or No, explains it in one sentence, and shows the clause it came from.

  • Status shown with an icon and a word, never colour alone
  • “Partly” always says what isn’t covered and what to do next
Where AI fitsAI can turn policy wording into plain answers, but a wrong answer costs real money. So every answer cites its clause, and anything unclear goes to a person.
9:41
My coverNorthwind Labs
Your family is covered
₹5,00,000 for you
₹40,000 used₹4,60,000 left
Ask about your cover
Partly covered

Gallbladder surgery is covered under your parents’ cover of ₹3,00,000. Rooms above ₹3,000 a day reduce what’s paid.

From your policy, section 3.4
See your estimateAsk a person
CoverClaimsHelpProfile
Flow 2 of 4

“How much will I have to pay?”

The cost of a room choice, in rupees

Explaining “proportionate deduction” in words doesn’t work. Showing the number does. Tap the rooms on the phone: a single room looks like ₹1,500 a day more, but it costs ₹34,500.

  • Each room shows what the family will pay, not just the daily rate
  • The 48-hour notice becomes a real deadline with a date and time
The mathsOver the limit, the insurer pays the capped rent and scales the ₹90,000 treatment cost by limit ÷ room rate. 3,000 ÷ 4,500 = 67% paid, so the family pays ₹34,500.
9:41
Plan Dad’s admission
This hospital isn’t on your insurer’s list. Tell us by Fri 30 Oct, 9 am to stay cashless.
Choose a room

Your parents’ limit is ₹3,000 a day

Estimate for 3 days
You’ll pay
₹34,500
Cover pays ₹69,000You ₹34,500

Over the ₹3,000 limit, so the insurer pays only 67% of the treatment cost too.

Notify insurer and continue
Flow 3 of 4

“Why did my claim bounce?”

Check the claim before it’s sent

Most delays come from missing or mismatched documents. At Surf, I redesigned expense claims so they were about 80% faster to raise. This applies the same idea to health claims.

  • Documents checked as they’re added, before the insurer sees them
  • Send stays locked until everything required is there. Tap “Add” on the phone
9:41
New claim
Dad’s follow-up after surgery

Post-hospital care · within 60 days of discharge

Claim amount₹6,840
Documents
Discharge summaryMatches the admission dates
Pharmacy bills (3)GST number and date found
Prescription missingNeeded for medicine bills
Payment proofUPI receipt matches the bill
CoverClaimsHelpProfile
Flow 4 of 4

“Why was ₹720 not paid?”

Every unpaid rupee gets a reason

A partial approval with no explanation is where trust breaks. Each line shows whether it was paid, and anything unpaid explains why and offers a review.

  • Paid and unpaid lines shown together, with the reason in plain words
  • A clear way to disagree, instead of calling HR
9:41
Claim decision
Partly approved
Approved
₹6,120
of ₹6,840
Paid to your bank in 2 days
What was paid
Follow-up consultation₹1,200
Prescribed medicines₹4,920
Protein supplement₹720 not paid
Why: nutritional supplements aren’t covered by your policy (section 5.3), even when a doctor suggests them.
Disagree? Ask for a review
CoverClaimsHelpProfile
9:41
Every screen can be tapped
04
The HR dashboard

Spot problems before the escalations

HR usually hears about a stuck discharge from an upset employee. This view shows it first, and turns employees’ questions into better choices at renewal, without exposing anyone’s medical details.

Select a claim, then escalate it

cover.app/northwind/benefits
Cover for HR
OverviewEmployeesClaimsPolicyRenewal

Benefits overview

Northwind Labs · 412 employees · policy renews 1 Jan 2027
Covered people1,036Employees and family
Haven’t added parents61Window closes 31 Oct · Remind
Never opened their cover38%Send a 2-minute tour
Discharges running late2Over the 3-hour limit
Claims that need attentionLive
Rahul S.Father · discharge approval
6h 40m
Priya K.Self · discharge approval
4h 05m
Arjun M.Spouse · documents requested
1 day
Rahul S. · Father
Admitted 19 Oct, cashless approved in 40 minutes
Hospital asked for discharge approval at 10:05 am
No decision after 6h 40m. The limit is 3 hours
Escalated to the insurer. Rahul has been told HR is on it.
Diagnoses and medical documents are never shown to HR.
What employees asked this monthAnonymous
Room rent limits23
Are my parents covered?17
Hospitals not on the list11
Maternity cover6
For renewal: room rent is your top question. A plan with no room cap would remove most of these. Compare it in January.

Late, not just open

Claims are sorted by how far past the 3-hour limit they are, so HR acts on the right one first.

Help without prying

HR sees who is waiting and for how long. Never the diagnosis or medical documents.

Questions become decisions

Anonymous question trends show where the policy confuses people, in time for renewal.

05
Decisions

What I chose, and what I ruled out

Insurance products are full of trade-offs between being clear, being correct and protecting privacy. These are the ones I’d expect to defend in a review.

01

Explaining cover

Answers to real questionsA nicer policy PDF viewer

People ask about situations. A better-looking document still makes them translate it themselves.

02

AI answers

Cite the clause, hand unclear cases to a personOpen chatbot answers

A confident wrong answer about cover can cost a family thousands of rupees. Every answer must be checkable.

03

Room limits

Show what you’d payA help article on deductions

The rule is hard to explain and easy to show. One number changes the decision.

04

Documents

Check before sendingLet the insurer ask later

Every round trip adds days. Catching a missing prescription on the phone takes seconds.

05

HR visibility

Who is waiting, and how longFull claim details

HR needs to help, not to know a diagnosis. Medical details stay between the employee and the insurer.

06

Employee questions

Grouped and anonymousLinked to names

Patterns help HR improve the policy. Names would stop people from asking.

06
Design system

One component carries most of the trust

The coverage answer appears in the app, in notifications and in claim decisions. Making it one component keeps the language and rules consistent everywhere.

Covered

Cataract surgery is covered up to ₹40,000 per eye.

Section 3.2 · Ask a person
Partly covered

Surgery is covered. Rooms above ₹3,000 a day reduce what’s paid.

Section 3.4 · See your estimate
Not covered

Glasses and contact lenses aren’t covered under this policy.

Section 5.1 · Check other benefits

Rules

  • A status word and an icon, never colour alone
  • Always one source clause
  • “Partly” and “Not covered” always offer a next step

Accessibility

  • All text colours pass WCAG AA (4.5:1)
  • Amounts read out in full by screen readers
  • Everything works with a keyboard

Data it needs

  • Structured policy rules: limits, sub-limits, exclusions
  • A clause ID for each rule
  • A confidence flag that routes unclear answers to a person
07
Measurement

How I would know if it worked

The goal isn’t more app usage. It’s fewer surprises and less back-and-forth for employees and HR.

MetricForWhy it mattersGoal
Claims accepted on first submissionEmployeeShows the document check is workingUp
Final bill within 10% of the estimateEmployeeThe truest measure of “no surprises”Up
Parents added during the joining windowEmployee and HRMissed windows are hard to fix laterUp
Benefits questions reaching HR, per 100 employeesHRShows the app answers questions on its ownDown
Answers sent to a personGuardrailIf it rises, the policy data or AI answers need workWatch

To test it, I’d run the new flows with two client companies for one policy year, compare them with similar companies, and survey employees after every claim.

08
Reflection

What I learned, and what’s still missing

Close to my day job

At Surf I designed payroll, reimbursements and employee self-service. Benefits have the same two-sided shape: the employee does the task, HR is accountable for it.

The hard part is data

Plain answers need policies turned into structured rules, and every insurer words them differently. That work decides how good the experience can be.

What I’d do next

This uses secondary research only. Next I’d interview five employees who used their company cover in the last year and two HR managers, then test the room estimate with families.

Sources and references7 links
  1. Onsurity survey of 1,150 employees, 2023, via Outlook Money.
  2. LocalCircles survey on claim approval and discharge waits, via Moneylife.
  3. IRDAI data on health insurance grievances, FY25, via Angel One.
  4. Plum, State of Employee Benefits 2026, via MediaBrief.
  5. IRDAI 1-hour cashless and 3-hour discharge rules, via BusinessWorld.
  6. Room rent limits and proportionate deductions, Business Standard and Outlook Money.
  7. General Insurance Council’s Cashless Everywhere, January 2024, via Onmanorama.
Thanks for reading

Happy to walk you through the decisions.

I’m a product designer in Hyderabad who designs for high-stakes money and benefits products.

shreeraj.ux@gmail.comSee more work

A self-initiated concept. “Cover”, “Northwind Labs” and “City Care Hospital” are fictional. Limits, clauses, names and amounts are illustrative; real policies vary.