Group Health Insurance / Group Mediclaim Policy

Group Health Insurance: Inclusions & Exclusions

• What Does a Group Health Insurance Policy Cover?

  Here are common coverages provided under medical insurance for employees:

  • Pre-existing Diseases: A corporate insurance policy, a type of group insurance policy, provides coverage for existing diseases before enrolling in the policy
  • Hospitalization Expenses: Medical insurance for employees covers in-patient hospitalization expenses, including room charges, nursing fees, and doctor's fees.
  • Pre and Post-Hospitalization: The policy covers expenses incurred before admission to the hospital and after discharge. This may include expenses for diagnostic tests and subsequent treatments.
  • Daycare Procedures: The corporate insurance policy covers medical procedures or surgeries that don't require overnight hospital stays. This may include treatment for cataract, stone removal surgery, chemotherapy, hemodialysis, etc. 

  Note: It's important to note that the coverage and terms may vary from one group health insurance policy to another. Therefore, it's important to carefully review the policy documents and understand the specific benefits and limitations of the plan.

• What Does a Group Mediclaim Policy Not Cover?

  Common exclusions under group health insurance policies in India often include:

  • Cosmetic Procedures: Cosmetic surgeries or treatments unless required by an accident or covered as a reconstructive procedure.
  • Dental and Optical Care: The policy does not cover routine dental and optical care. However, some policies may offer limited coverage for dental and optical treatments.
  • War or Nuclear Risks: The health insurance for corporates doesn't cover Injuries or illnesses resulting from war, nuclear radiation, or related risks.
  • Hazardous Activities: The policy excludes medical emergencies resulting from engaging in hazardous activities like adventure sports or high-risk occupations.
  • Self-Inflicted Injuries: Injuries that the insured person deliberately causes are not covered.
  • Substance Abuse: The health insurance for corporates excludes medical conditions resulting from drug or alcohol abuse.
  • HIV/AIDS: The group health insurance scheme does not cover treatment and expenses related to HIV/AIDS.
  • Non-Medical Expenses: The policy does not cover non-medical expenses like transportation, accommodation and personal comfort items during hospitalization.
  • Experimental or Unproven Treatments: The corporate insurance policy excludes treatments or drugs that are experimental or not widely recognized.
  • Injuries from Illegal Activities: The policy doesn't cover injuries or illnesses resulting from illegal activities or involvement in criminal acts

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

  Below is a table comparing group health insurance for employees and individual health insurance.

  Group Health Insurance	Individual Health Insurance
  The company is the direct point of contact 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 group health insurance policy.	In an individual health insurance policy, the individual policyholder has the authority to cancel the policy.
  A corporate medical 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 plan majorly depends on the strength of the company. This includes both employee and financial strength.	An individual health insurance policy majorly depends on the age of the individual, his/her health condition, age, etc.
  Pre-medical tests are not conducted in a group health insurance plan.	Most insurance providers perform pre-medical check-ups before issuing a policy to an individual.

• Is corona virus covered in Group Health Insurance?

  Some group health insurance plans provide coverage for corona virus. However, you should check with your employer or insurer for the same.

• Is it possible to issue the group mediclaim policy with fewer than 7 employees?

  Yes, if the number of employees is less than 7 but the total number of lives, including dependents, exceeds 7, then the insurance company will issue the employee medical insurance in India.

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

  The insurance company decides the premium of a Group Health Insurance policy based on the:

  • Number of employees in an organization,
  • Average age of employees,
  • Number of dependents
  • Location

• What are the various waiting periods in Group Medical Insurance?

  Health insurance for corporates often eliminates waiting periods seen in individual policies. Typical waiting periods include:

  • 9 Months Waiting Period: Under the group health insurance plan that includes maternity benefits, there is a 9-month waiting period before a claim can be raised. However, the company can waive this waiting period, providing coverage from day 1.
  • 1 Year Waiting Period: Group health insurance typically excludes high-incidence diseases such as Gallbladder, Cataract, and Kidney stones. The insured must serve a 1-year waiting period before raising a claim. However, the company can waive off this waiting period if desired.

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

  Room rent capping limits the type of hospital room that the patient can use. Typically, the insurer sets this cap at 1% of the sum assured, and the insured bears the costs exceeding this cap. This measure helps control expenses and ensures clarity in healthcare billing. However, one can remove the room rent cap by choosing higher room rent limits when purchasing the policy.

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

  Yes, the option for room rent customization is available in the Group Health Policy. There are several options available for customization, including:

  • Proportion of Sum Assured (1%, 1.5%, & 2%)
  • Single AC room (irrespective of the costs)
  • No room rent capping at all

  *Note: Room rent customisation in medical insurance for employees varies from one insurer to another.

• Is it advisable to opt for a pre-existing disease waiver in group health insurance for employees?

  Including a pre-existing disease waiver in group mediclaim insurance depends on the group's demographics and desired benefits. For example, if the group primarily comprises young individuals without significant medical histories, the importance of this benefit may be relatively lower.

  However, if the group consists of members with an average age of 40, including parents, the significance of this benefit increases.

• Can maternity coverage be included in a group medical insurance policy for employees?

  Yes, you can add maternity benefits to your employee's group health insurance policy. However, it's important to note that maternity coverage typically comes with a maximum claim limit specified in the policy.

• Why is the maternity benefit important?

  Maternity benefits are important in India for multiple reasons. They provide essential medical care and financial security for mothers during pregnancy and childbirth. This ensures the health of both mother and child.

  The Maternity Benefit Act, 1961 mandates these benefits, protecting women's rights and promoting workplace equality. Additionally, these benefits help retain female employees by allowing mothers to care for their newborns during the early months.

• Is internal congenital disease covered under a group medical insurance policy?

  It is a standard exclusion for most insurers. However, this exclusion can be waived if the employer pays an additional premium.

• What is the facility for a health check-up under a group medical insurance policy?

  Health insurance for corporates offer coverage for regular health check-ups, typically provided once every four years. This valuable benefit serves as an added service for corporate customers.

• What information is needed to generate employee medical insurance quotes?

  To obtain insurance quotes from various insurance companies, the following information is required:

  For Fresh Cases: For new policy proposals where the client is purchasing the policy for the first time, the following employee data is necessary and should be provided in the Excel template provided:

  • Employee Code
  • Employee Name
  • Relation (Self, Spouse, Child, or Parent)
  • Date of Birth
  • Gender
  • Sum Insured for all employees and their dependents, if applicable.

  For Renewals or Market Rollovers: For policy renewals or market rollovers, we need the following:

  • Copy of the previous year's policy
  • Claims dump
  • Claims Management Information System (MIS)
  • oActive employee data, including employee information.

• What information is needed to generate employee medical insurance quotes?

  Generally, insurance companies do not provide coverage to specific employees.

• Why is data required for group medical insurance policy quotes?

  Insurance policies, especially Medical Insurance for Employees, are tailored to specific factors like age demographics, gender distribution, location, and sum insured. Underwriters calculate premiums based on these variables. Without accurate data, it's impossible to assess the risk properly and provide accurate quotes. By providing precise information, we can offer you the most suitable and competitive quote.

• Why is the date of birth required, and why can't the quote be provided based solely on age?

  The insurance company determines the rates for Group Health Insurance (GHI) policies on the basis of specific age brackets. If you provide an approximate age instead of the date of birth, the premium estimate may not be accurate. This is because the premium varies depending on the age bracket of the employees.

  For example, if the employer estimates an employee's age as 35. Later, learns that the employee's age is 36 by their date of birth. This will result in age bracket changes, leading to a corresponding change in the premium amount.

• Can group health insurance policy provide coverage for dependents?

  Yes, a group insurance scheme offers various family definitions to accommodate different coverage needs::

  • Employee Only: This option covers only the employees of the company.
  • Employee and Spouse (ES): This choice provides coverage for both employees and their spouses.
  • Employee, Spouse, and Kids (ESK): This category includes coverage for employees, spouses, and children.
  • Employee, Spouse, Kids, and Parents or Parents-in-Law (ESKP): This option extends coverage to employees, spouses, children, as well as parents or parents-in-law.

• What is the impact of room rent on the claim amount payable?

  When the policyholder selects a room above the policy's tariff limit, the insurer will proportionally reduce the claim amount. The policyholder must then pay the difference.

• Is vaccination covered in Group Health Insurance

  Yes, the covered newborns receive vaccinations as part of the Group Health Insurance policy's terms and conditions..

• What is the difference between ESIC and a group health insurance plan?

  ESIC (Employees' State Insurance Corporation) is a compulsory government-operated measure. It offers medical benefits to specific employees depending on income thresholds and industry categories.

  In contrast, a group health insurance plan is voluntary and provided by employers. It offers medical coverage to their employees. Unlike ESIC, employee group insurance plans provide greater flexibility in coverage options and benefits.

• Who pays the premium for the group mediclaim policy?

  In most cases, the employer pays the premium for the group medical insurance policy. However, some companies may choose to share the cost with their employees or offer the option for employees to contribute towards enhanced coverage for themselves or their family members. ..