Disease-wise Capping in GMC to Manage Price

Group health insurance is one of the most attractive perks a company provides. Companies that offer group health plans to their employees stand out of the crowd and attract good candidates. However, in order to provide hassle-free service to the employees, the company along with the insurer has to manage certain important aspects one of which is disease-wise capping.

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Disease-Wise Capping

Disease-wise capping refers to the point where you purchase a group health insurance plan with a particular amount of sum insured, let’s just say Rs 5 lakh. Out of this amount, the insurer restricts the maximum payout for a particular set of illnesses up to Rs 1 lakh. In simple words, if the insured raise a claim for more than Rs 1 lakh for a particular set of treatment, they will have to pay the rest of the amount out of pocket.

Here is an example, Rohan is an employee of a tech company. He is working with that company for the past 2 years and he is covered under the group health insurance plan.

In 2019, Rohan’s right eye started itching and he started having a problem with his vision and after some time the eyes started watering. He goes to the doctor for a check-up. The doctor said that he has to get treatment for conjunctivitis but during the check-up doctor also notices that Rohan has developed a cataract in the right eye.

Rohan goes for the surgery and the final billing amount totalled Rs 30,000. Rohan thought that the group health insurance plan would cover the whole amount but little did he know that the disease-wise capping for cataract surgery was set at Rs 20,000. Now the group health insurance provided coverage for Rs 20,000 and Rohan has to pay the rest of the Rs 10,000 out of pocket.

Illustration of Disease-wise Capping Slabs

In the table below we have mentioned the disease-wise capping slabs. They are as follows:

Lower Sub-limits

Diseases

Metro

Non-Metro

Appendix

12,000

10,000

Eye related

17,000

15,000

Gall Bladder

15,000

15,000

Hernia

12,000

10,000

Hydrocele

7,000

5,000

Hysterectomy

20,000

17,000

Piles

10,000

7,000

Kidney Stone (inc DJ stent removal for same stone)

30,000

25,000

Joint Replacement including Vertebral joints

75,000

70,000

 

Standard Sub-limits

Diseases

Metro

Non-Metro

Appendix

20,000

18,000

Eye related

25,000

22,000

Gall Bladder

22,000

22,000

Hernia

20,000

18,000

Hydrocele

15,000

12,000

Hysterectomy

28,000

25,000

Piles

18,000

15,000

Kidney Stone (inc DJ stent removal for same stone)

35,000

30,000

Joint Replacement including Vertebral joints

85,000

80,000

 

Higher Sub-limits

Diseases

Metro

Non-Metro

Appendix

24,000

19,000

Eye related

30,000

25,000

Gall Bladder

30,000

25,000

Hernia

24,000

19,000

Hydrocele

18,000

14,500

Hysterectomy

34,000

29,000

Piles

19,000

15,500

Kidney Stone (inc DJ stent removal for same stone)

40,000

35,000

Joint Replacement including Vertebral joints

110,000

90,000

*Sub-limits mentioned in the table are for reference purposes, actual sub-limits may vary as per the insurer's underwriting guidelines.

Here is another case scenario, Mr. Rahul, covered under Group Health Insurance, goes for Knee Joint Replacement Treatment in Mumbai. The treatment was successful, Mr. Rahul submitted a claim of Rs 1,50,000 to the Group Health  Insurance Company. Mr. Rahul's Group Health Insurance Policy had a Diseases-wise Capping with Lower Sub-Limits which resulted in an out pocket expense for him with proportionate deductions as per the sub-limits.

Now you must be able to understand the concept of disease-wise capping. This is why it is advised to purchase group health insurance with no disease-wise capping so that the employee does not have to pay any amount out of pocket.

Conclusion

The purpose of purchasing a group health insurance plan is to provide healthcare benefits to the employees as well as their dependents so that they do not have to pay out of pocket. But in the case of disease-wise capping if the final billing amount crosses the capped amount then the employee has to pay for it out of pocket that kills the whole purpose of offering group health plan. So while purchasing the group health plan, make sure that there is no disease-wise capping limit so that the employee does not have to worry about any kind of expense.

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Written By: PolicyBazaar - Updated: 09 February 2022

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