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Group Health Insurance

Health Is Wealth is a very famous saying, and everyone tries different methods to maintain their wellbeing. However, life never follows a fixed pattern and thus, bodily injury or sudden illness can occur to anybody and may leave one both financially and physically stressed. Therefore, it is always good to have a medical insurance policy for such situations.

There are various different types of health insurance policies available in the market and group health insurance is one. A group health insurance plan is used to provide risk coverage to the people who belong to a specific group. Generally, this policy is given by employers to employees.

Group health insurance policies come in different variations and every organization can customize a plan according to the requirements of its employees. There are some group health insurance plans that cover the families of the insured people as well. So, it entirely depends upon the organization what kind of group health insurance plan it selects.

When the group health insurance is provided by the employer, then both employee and employer are supposed to be the beneficiary. This is because; the plan addresses both the parties of a group.

Advantages of Group Health Insurance Policies

The group health insurance policy for employees is advantageous for both employer and employee:

Advantages for Employers:

  • Helps in Employee Retention: In this modern era when there are a lot of jobs in all the fields, employee retention has become a difficult task. However, if the employer provides benefits like health insurance coverage to all its employees and his/her families as well, then the chances of an employee staying in the company increase.   
  • Tax Benefits: As mentioned above both employer and employees are the beneficiaries in a health insurance plan for the group, thus the employer also gets tax benefits for providing such policies to its employees.
  • Motivated Employees: Today, when the medical costs are at its peak, having a health insurance plan, motivates employees.
  • Better Benefits in Low Cost: Health insurance for employees provide better benefits in comparatively lesser cost than individual health insurance policy.

Advantages for Employees:

  • Pre-Existing Disease is Covered from Day 1: Unlike any individual health plan, a group health insurance policy starts covering pre-existing diseases from the day an employee joins the organization. In this way, there is no waiting period for any pre-existing disease.
  • An Extensive Range of Coverage with No Limited on Diseases: Apart from covering pre-existing diseases, a group health insurance plan for employees provides a wider coverage with no limit on diseases.
  • Larger Maternity Coverage: A wider maternity cover is one of the best advantages given to young employees. Most of these plans provide coverage for both C-section and normal deliveries. Some plans as well cover the newborn babies without a standard 90 days of maternity cover.

Benefits of Group Health Insurance Policy

Employees are the treasured part of any organization. These days more and more companies are becoming employee-centric and corporate health insurance has emerged as one of the most preferred benefits to lure new talent. It plays a crucial role in influencing the psychology of an employee. It makes him feel part of a company and thus, it curtails employee attrition rate and unrest in labor unions. Moreover, it increases their productivity which increases profitability of a business. Special insurance schemes where families are also covered for benefits make employees faithful towards their employers. Moreover, by offering coverage to your employees, you become eligible to get tax deductions under Income Tax Act. So group health insurance policy is a win-win situation for both employees and employers.

Features of Employee Health Insurance Plans

There are several group health insurance policies available in the market. Listed below are some common features present in all employee health insurance plans.

  • Employee health insurance companies typically cover medical benefits for insured (self), spouse, children and dependent parents
  • Some health insurance providers cover pre-existing illness and maternity as well
  • Employee health insurance offers cashless hospitalization at network hospitals
  • Group health insurance can cover ancillary charges such as ambulance costs too.
  • Some employee health insurance policies provide fee reimbursements of specialists and other medical practitioners for follow checkups

Why Is Group Health Insurance Required?

Employees are the treasure of any organization and thus the companies provide various facilities to give them a healthy work environment. These days organizations are becoming more employee-centric than before and hence they offer health insurance plans to its employees. Some of the reasons why group health insurance plans are required and beneficial for both employers and employees are:

  • Wide Coverage and Better Benefits: Most of the group health insurance plans provide wide coverage and elaborated benefits to the policyholders.
  • Option to Get Customize Cover: The health insurance policies for groups give the option to customize coverage. For example, an employer can take a plan that provides maternity cover or OPD coverage.
  • Affordable Premiums: Comparing individual health insurance plan with group health insurance in terms of premiums shows groups health plan as affordable. This is because the premiums that one has to pay in respect of coverage that one gets is always higher in group health plans.

Inclusions

The common inclusions that most of the group health insurance plans provide to its policyholders are:

  • Pre-existing diseases are covered from day one.
  • Maternity cover is provided in all the group health insurance plans; however, some has a waiting period of 9 months whereas some do not.
  • The infant is covered from the day of his/her delivery.
  • Some plans also cover ambulance charges.
  • Pre and post-hospitalization expenses.
  • Domiciliary and daycare expenses.
  • Fees of a medical practitioner and specialists.
  • Room rent and nursing charges.
  • Anesthesia, oxygen, blood, OT charges, medicines, drugs, and cost of diagnostic such as x-ray, etc.
  • Some plans also cover radiotherapy, chemotherapy, pacemaker cost, etc.

Exclusions

The common exclusions that all the plans under this category have been:

  • Some policies do not cover the parents of the employee.
  • Non-allopathic treatments like homeopathy, Ayurveda, etc. are not covered.
  • The validity of a health insurance policy for employees is always limited and is valid only until the employee works with the organization.
  • Congenital diseases and all the expenses incurred in the treatment of AIDS and other related alignments.
  • Alignment or complications arising out of the use or abuse of alcohol or drug.

Documents Required for Making a Claim

Documents always play a major role in the approval of the claim. The list of documents required in this case while making a claim are:

  • Duly filled claim form with the sign of concerned doctor or hospital.
  • Final investigation report.
  • Doctor’s prescription.
  • Medical reports.
  • Final bill with the breakup.
  • In case of accident, police report.
  • Cash memos and itemized bills.
  • Discharge summary with a suggested line of treatment.
  • Any other document required by the health insurance provider.

Note: The policyholder has to submit the original copies of all the documents.

How to Claim?

The common steps that most of the health insurance providers follow in order to file a claim are:

  • Contact the health insurance provider in order to file a claim as soon as possible by calling the toll-free number.
  • The customer care representative guides on the claim process and all the documents required.
  • An insured can download the claim form from the website of the insurance provider or can ask for the same to the customer care representative of the company.
  • Duly fill and sign the claim form.
  • Attach all the required documents with the form.
  • Send the claim form with all the documents to the specific address of the insurance provider.

Note: The policyholder is suggested to keep the copy of all the documents and claim form with him/her.  

Buy Group Health Insurance Policy at PolicyBazaar

Group health insurance is a medical insurance that covers a group of people, who are usually the members of societies, employees of a common company, or professionals in a common group. Group health insurance helps companies identify and mitigate the risks faced by their employees. Rising costs of healthcare have made it necessary for every employer to cover their employees and their families from financial instability that may arise in case of hospitalization. Also, group health insurance helps companies in attracting talented staff. Whether you are a small group or a company, you can easily retain best talent in the industry by offering comprehensive health insurance coverage.

Almost all health insurance companies offer flexible covers at affordable premium rates, which depend on conglomeration of factors, like size of the group, profile of members, etc.  It works under certain terms & conditions, which are applicable to all insured members.

At PolicyBazaar, we strive to use highly innovative approach to help you in comparing best health plans. Compare and choose the right health plan, which provides coverage to all members in a single policy.

Want a Healthy Workforce? We can Help!

It is no secret that employees’ value benefits of group health insurance. However, as premium costs escalate and claim procedure being stringent; employee health insurance has become a tight rope walk in India. We at PolicyBazaar introduce a wide gamut of group health insurance policy products to help you in choosing best corporate insurance plans that will suit both parties i.e. employers and employees. Blending the entire service right from expert advisory, purchase assistance and policy renewal in one package, PolicyBazaar works towards making insurance process easy and convenient.

Written By: PolicyBazaar - Updated: 16 September 2019
Q:

What is Group Health Insurance?

Ans:

Group Health Insurance (or Group Mediclaim) provides healthcare coverage to a group of people belonging to a common community (typically as employees of a company). Group Health Insurance plans are generally uniform in nature, offering the same benefits to all employees or members of the group. However, the biggest advantage of Group Health Insurance is that it can be customized to meet unique needs of the company.

A group health insurance policy offers several other benefits employees cannot get to avail of on an individual basis. These benefits include coverage for pre-existing diseases. In case of a group health insurance policy, an individual does not have to wait for specific diseases to be covered (i.e. there is no waiting period), including maternity coverage. A customized insurance coverage can be enjoyed only with the group medical insurance scheme, making the employees feel more secure when it comes to health.

Most of the companies provide Group Health Insurance as a part of their Employee Welfare program. Every company, however, opts for a plan that is customized, based on their requirements. 
Q:

What different covers are available?

Ans:

It is very critical to customize a Group Health Insurance plan for each group. Read the benefits provided in group health insurance below. Each group can customize the benefit structure, based on its unique need. Click on the below link to learn more about how each attribute can be customized in Group Health Insurance.

1. Maternity Benefit

2. Waiver of waiting periods (30 days, 1 year, 2 years, & 4 years)

3. Domiciliary Hospitalization Expenses

4. Pre-Existing Disease Covers

5. Cover for dependents (spouse, kids, parents)
Q:

What are various waiting periods in Group Insurance?

Ans:

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.
Q:

What is the ‘30-days’ waiting period?

Ans:

This is put by the Insurer to ensure that policy was not taken for a planned surgery immediately after the policy. Hence, emergency hospitalization and accident cases are covered in this period. All other hospitalization cases are not covered for the first 30 days of the inception of the policy. This condition can be waived off (if desired).
Q:

What is the one-year waiting period?

Ans:

Group health or medical insurance policies exclude certain high incidence diseases, including Cataract, Kidney Stone, and Gallbladder etc. The list of ailments varies from Insurer to another. Because of this condition, the member cannot claim this benefit until the expiry of 1 year in the plan. This condition can be waived off, if desired, under group insurance.
Q:

What are 2-year and 4-year waiting periods?

Ans:

Several insurers would extend the waiting period for above-discussed ailments to 2 years and 4 years, respectively. This condition can be waived off (if desired).
Q:

What is the ‘9-months’ waiting period for maternity?

Ans:

Group health insurance policies that provide maternity benefits have a 9-months waiting period before the person can claim the benefit. However, if the company so desires, this waiting period can also be waived off, essentially making the member eligible to claim maternity benefit from Day 1.
Q:

What is room rent capping in Group Insurance (Group Mediclaim)?

Ans:

Hospital costs are dependent upon the type of room selected, e.g. fees for doctor consultation in single A.C. room would be higher when compared to the shared room in the hospital. Hence, insurance companies put conditions on room eligibility. All costs thereafter are payable as per the eligible room rent. Typical eligibility is 1% of sum assured as room rent cap.
Q:

How does health-care cost vary by room type?

Ans:

Below figures, shows the cost of Single AC room and Shared Room, along with are mentioned the package cost of Heart By-pass surgery for these rooms respectively. These are actual costs for a leading hospital in Delhi.

Room rent per day:

1. Single AC Room: 9900

2. Shared Room: 4000

Cost of heart surgery by room type:

1. Single AC Room: 292,000

2. Shared Room: 200,000
Q:

How does claim admissibility vary by room type?

Ans:

In case the policyholder selects a room with higher rent than the one mentioned in the policy document, the charges to be paid shall be limited to the charges applicable to the entitled category.

So if for instance, one had a health policy with sum assured of Rs. 4 Lakhs, and a room eligibility of up to Rs. 4000, then the claim payable would be limited to Rs. 2 Lakhs. So despite the sum assured being much higher, the Insured would have to pay 92,000 out of pocket.
Q:

Can room rent be customized under group insurance policy?

Ans:

Fortunately, one can customize the Group Health policy to choose the room rent type. Following options are available:

1. As proportion of Sum Assured (1%, 1.5%, & 2%)

2. Single AC room (irrespective of the costs)

3. No room rent capping at all
Q:

How are pre-existing diseases covered in Group Health Insurance?

Ans:

The primary advantage of group health insurance is that one can enhance the coverage over a standard policy. One such benefit that most companies take while buying Group Insurance is the pre-existing diseases. A few commonly asked questions regarding pre-existing diseases are mentioned below:
Q:

What is a Pre-existing disease?

Ans:

A pre-existing disease is an ailment or sign of an ailment present before the inception of the insurance policy. For instance, many of the cardiovascular diseases are classified as pre-existing diseases, in case one has a heart attack. The same is valid in case one has a problem of severe blood pressure abnormalities, which can also be classified as a pre-existing disease in the name of cardiovascular issue.
Q:

Are pre-existing diseases covered in a standard health insurance?

Ans:

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 of 3 years. Pre-existing medical conditions are permanently excluded before policy issuance. This is in order to prevent any fraud or misuse so that people do not buy insurance to over pre-existing diseases.
Q:

Can pre-existing be covered from Day 1 in Group Health Insurance?

Ans:

Yes. Group health insurance policies offer coverage for pre-existing diseases right from day one. Since group insurance is purchased for numerous families together, the chances and the impact on frauds are considerably reduced. Hence this benefit can be offered by Insurance companies.
Q:

Should we go for pre-existing disease waiver?

Ans:

It depends on the demographic to be covered and the benefits you want to offer to your group members. For instance, if the group includes youngsters who don’t have a medical history, including coverage for a single person, the benefits of the policy are comparatively less important. On the other hand, if the group has an average age of 40 with parents covered, then the significance of this benefit is much more.

In addition, it is dependent on the group’s policy as well as on the cost it wishes to incur. Some group members might be entitled to the benefits of the policy only after they have been with the system for 4+ years. At the same time, this benefit comes only at an additional cost.
Q:

What is maternity Benefit in Group Health Insurance?

Ans:

One of the key benefits that young employees value in the Group Health Insurance (Group Mediclaim) provided by the company is the Maternity Benefit.  There are several aspects to the Maternity benefit that should be considered while designing and purchasing the group health insurance plan. These aspects are covered below:
Q:

How is maternity sum assured different from overall sum assured under group health insurance?

Ans:

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.

The market average is to provide 25,000 as sum assured for Normal and 35,000 for C-Sec delivery. While most Insurance companies limit the benefit to 50,000, some would provide as high as 100,000.

Group insurance plans for young group offers maternity benefits. Hence HR managers have to evaluate the extent of benefit to be offered carefully.
Q:

What is the application of co-pay on Maternity?

Ans:

In case your policy has co-pay, it is generally not applicable for the maternity claims. The rational being that benefit is already capped. However, it is important for your Insurance Broker to clearly specify this in the policy terms since ambiguity later can lead to claim disputes and employee dissatisfaction.
Q:

What is the cover for Abortion in Maternity?

Ans:

Group Health Insurance generally does not cover self-inflicted, or fertility related treatment. Similarly, voluntary abortion is not covered under Group Health Insurance by most Insurance companies. However, emergency abortion, i.e. for the life-saving purpose is covered by most insurance companies. It is important to note that each company has its own view on this, so important to get it clarified through your insurance broker.
Q:

Does the policy provide coverage to a newborn baby under maternity coverage?

Ans:

In a standard policy, a newborn is not covered under the health insurance policy unless it is at least 90 days old (some companies increase the restriction to make it 150 days). However, one can get it customized to cover a newborn from Day 1. Within this, the employer has a choice to fix the sum assured for the newborn for the period between 0-90 days. It can be either the maternity sum assured or the sum assured available to the employee. It is highly recommended that the higher sum assured should be chosen, since if any complication arises to the newborn, the maternity sum assured would be highly inadequate.
Q:

What is the waiting period for maternity?

Ans:

Some of the individual policies that offer maternity benefit have a waiting period of 3-4 years. However in a Group Health Insurance (or Group mediclaim) the waiting period comes down to 9 months i.e., the member should be at least be enrolled in the policy for nine months. This condition for 9 months waiting period can also be waived if desired by the company. This would mean that from Day 1 of the policy, the enrolled members can claim the maternity benefit.
Q:

Is internal congenital disease covered under group health insurance?

Ans:

It is a standard exclusion with most insurers. Again, this exclusion can be waived off and get it covered in the group insurance policy. Do note that all companies do exclude external congenital disease.
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