Group Health Insurance FAQ’s

A group health insurance plan is a health insurance plan that provides coverage to members of a group that tends to be employees of a company or members of an organization. Members of the group usually receive insurance at a reduced cost because the insurer’s risk is spread across a group of policyholders. Generally, this policy is given by employers to employees. The advantage of a Group Health Insurance policy is that it can be customised to each specific group depending on what extent (Sum Insured) and how comprehensive they want the coverage to be. Some organisations look to not only cover their employees, but their dependant family as well.

  • Pre-Existing Disease Coverage from Policy inception
  • Enhanced Maternity Benefit + Baby Day 1 coverage
  • Waiver of waiting periods for benefits with them
  • Domiciliary Hospitalization Expenses + Day Care Procedures covered
  • Cover for dependents (spouse, kids, parents)

Hospital costs are dependent upon the type of room selected by the insured and also based on availability at the time of admission…hence doctor consultation in single A.C. room would be higher when compared to the shared room in the hospital. All related costs thereafter are payable as per the eligible room rent. Typical eligibility is 1-2%% of sum assured as room rent cap and this can be increased.

A standard individual health insurance policy has several waiting periods for specified reasons and diseases. One of the biggest advantages of having a group insurance (or group mediclaim) is that these waiting periods can be waived off. Also, it is important to understand the implications of the waiting periods.

Your policy may provide cover for a wide range of ailments in addition to accidents which need ‘in-patient’ hospitalization. Besides, you can opt for a critical illness cover as well.

Pre-existing ailment/disease is a condition or sign of the same present before at the inception of the insurance policy for which the insured is on continuous medication/treatment for. Many insurance companies start providing coverage for pre-existing diseases after a waiting period of 4 years. Some other insurers would have a lower criterion and in some cases where they are even waived off. This is in order to prevent any fraud or misuse so that people do not buy insurance to cover specifically pre-existing diseases., which would be treated as anti selection.

Some health insurance policies pay for specified expenses towards general health check up once in a few years. Normally this is available once in four years and is mainly offered as a value add to their corporate customers.

One of the important benefits that young employees value in the Group Health policy provided by the company is the Maternity Benefit. It is important to note that the maternity sum assured is different from the overall sum assured of the group mediclaim policy. This sum assured is fixed different for Normal and Caesarean delivery. Generally, companies provide higher sum assured for Caesarean delivery, which is between Rs.25,000 as Normal and Rs.35,000 for Caesarean delivery. This can be higher based on the group seeking a review of these limits.

Group Health Insurance generally does not cover self-inflicted or voluntary abortion under Group Health Insurance offered by most insurers. However, emergency abortion which is medically required, i.e. for the life-saving purpose is covered by most insurance companies.

Insurance companies, through Third Party Administrators (TPA’s) have arrangements with several hospitals all over the country as their network to offer cashless treatment for individuals. This means that the insured can get treatment without having to pay the hospital bills as the payment is made to the hospital directly by the Third Party Administrator, on behalf of the insurance company. However, expenses beyond the limits or sub-limits as per terms and conditions of the policy and expenses not covered under the policy have to be settled by the insured directly with the hospital. Cashless facility, however, is not generally available if you take treatment in a non network hospital.

Yes, most policies follow the standard practice of coverage from the 91st day post birth, but some insurers offer cover from Day 1.

It is a standard exclusion with almost all insurers.

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