Group Health Insurance

Group Health Insurance: Inclusions & Exclusions

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

• What is Covered?

  • Pre-existing diseases are covered from day one.
  • Maternity coverage is provided in all the group health insurance plans; however, some have 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.

• What is not Covered?

  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 corporate 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 ailments.
  • Ailment or complications arising out of the use or abuse of alcohol or drug. 

• How is a group health insurance policy different than an individual health insurance plan?

  Group Health Insurance	Individual Health Insurance
  The company is the direct point of compact for a group health insurance plan.	In the case of individual health insurance, an individual is the point of contact.
  The employer holds the authority to cancel the policy.	In an individual health insurance policy, the individual policyholder has the authority to cancel the policy.
  A group health insurance policy is valid until the employee is with the respective organization.	An individual health insurance policy is valid until an individual pays the premium for his/her policy.
  A group health insurance policy majorly depends on strength of the organization, which includes both employee and financial strength.	An individual health insurance policy is majorly dependent on the age of the individual, his/her health condition, age, etc.
  Pre-medical tests are not conducted in a group health insurance plan by the insurance provider.	Most insurance providers perform pre-medical check-ups before issuing a policy to an individual.

• Is coronavirus covered in Group Health Insurance?

  Some group health insurance policies provide coverage for coronavirus, however, you should check with your employer or insurer for the same.

• Who can be covered in a group health insurance policy?

  All employees who are more than 18 years old and below 70 years and are employed with a company are eligible to get cover for a Group Health Insurance policy. In addition to that, they can as well add their dependent children who are between 3 months to 25 years, spouse, and sometimes even parents.

• How is the premium of a Group Health Insurance decided?

  The premium of a Group Health Insurance policy is decided according to the number of employees in an organization, their age, number of dependents, and location.

• What are the various waiting periods in Group Insurance?

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

  • Waiting Period of 30 Days: This is put by the Insurer to make sure that the 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).
  • Waiting Period of One Year: Group health or medical insurance policies exclude certain high-incidence diseases, including Cataract, Kidney stones, Gallbladders, etc. The list of such ailments varies from one Insurer to another. Because of this condition, the members cannot claim this benefit until the expiry of 1 year in the plan. However, under the Group Health Insurance policy, this condition can be waived off, if desired.
  • Waiting Period of 2 Years and 4 Years: Several insurers have a waiting period of 2 to 4 years for many pre-existing diseases. The list of such pre-existing ailments may vary with the insurer. So, you have to go through your policy documents for getting to know about the waiting period of 2 to 4 years.
  • Waiting Period of ‘9-months’: Group health insurance policies that provide maternity benefits have a 9-month 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 benefits from Day 1.

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

  Hospital costs are dependent upon the type of room selected, e.g. fees for doctor consultation in a 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 the sum assured as a room rent cap.

• How does the healthcare cost vary by room type?

  The below figures, shows the cost of a Single AC room and a Shared Room, along with are mentioned the package cost of Heart Bypass 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

• How does claim admissibility vary by room type?

  In case the policyholder selects a room with a 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 a sum assured of Rs. 4 Lakhs, and 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.

• Can room rent be customized under the group insurance policy?

  Fortunately, one can customize the Group Health policy to choose the room rent type. The following options are available: 1. As a proportion of Sum Assured (1%, 1.5%, & 2%) 2. Single AC room (irrespective of the costs) 3. No room rent capping at all

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

  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 pre-existing diseases. Let us discuss the pre-existing disease concerning Group Health Insurance extensively:

  • Pre-Existing Disease: A pre-existing disease is an ailment or sign of an ailment present before the inception of the insurance policy. For instance, many 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 with severe blood pressure abnormalities, which can also be classified as a pre-existing disease in the name of cardiovascular issues.
  • Pre-existing Disease Coverage: Many insurance companies have started 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 to prevent any fraud or misuse so that people do not buy insurance to cover pre-existing diseases. 

  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 of fraud are considerably reduced. Hence this benefit can be offered by Insurance companies.

• Should we go for a pre-existing disease waiver?

  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. Also, it is dependent on the group's policy as well as on the cost it wishes to include. 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.

• What is the Maternity Benefit in Group Health Insurance?

  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:

  • Amount of Maternity Coverage: The maternity sum assured is different from the overall sum assured of the group mediclaim policy. This sum assured is fixed differently for Normal and Caesarean delivery. Generally, companies provide a higher sum assured for Caesarean delivery. The market average is to provide 25,000 as the 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.
  • Co-Pay in Maternity Cover: In case your policy has a co-pay, it is generally not applicable for maternity claims. The rationale is that benefit is already capped. However, your Insurance Broker needs to specify this in the policy terms since ambiguity later can lead to claim disputes and employee dissatisfaction.
  • Coverage for Abortion in Maternity Cover: Group Health Insurance generally does not cover self-inflicted, or fertility-related treatments. 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 view on this, so it is important to get it clarified through your insurance broker.
  • Coverage for a Newborn Baby Under Maternity Cover: 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.
  • Waiting Period for Maternity: Some of the individual policies that offer maternity benefits 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 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.

• Is internal congenital disease covered under group health insurance?

  It is a standard exclusion for 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 diseases.

• What are some specific coverages provided under the Group Health Insurance policy apart from some standard cover?

  The specific coverages under this plan are:

  • Coverage for pre-existing diseases from the start of the policy.
  • Waiting period waiver.
  • Enhanced benefits for maternity and covers a baby from day 1.
  • Provides cover for dependents (kids, spouse, and parents).
  • Expenses of domiciliary expenses and covers daycare procedures.

• What is the facility for a health check-up?

  Some health insurance plans pay for the expenses of general health check-ups at least once in some years. Generally, this facility is available once every four years and is provided as a value-added service for corporate customers.