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Group Health Insurance

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.
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The policy offers:
  • Offers Cashless Coverage across Network Hospitals in India – Direct settlement of hospital bills between Insurer/TPA and Hospital
  • Most Group Health Policies cover Pre Existing Medical conditions (unlike Individual Health policies which carry a waiting period) from the inception of the policy.
  • Maternity Benefits (for both normal and caesarean deliveries) are covered.
  • Infants born under the policy are covered from Day 1 (unlike Individual policies, which cover new born babies from Day 91)
  • Most policies cover in hospital medical treatment where insured has been hospitalised for a minimum of 24 hours.
  • Day care procedures like Cataract surgery, Nasal Sinus Aspiration, Stapedectomy of the Ear , Chemotherapy / Radiation etc are covered under most policies – these procedures do not require 24 hour hospitalisation
  • Domiciliary Expenses are covered in most policies.
  • Pre and Post Hospitalisation is covered by some insurers may extend the duration of these coverages
  • Some policies may cover boarding expenses apart from surgeon, anesthetist and consultant fees; charges for anesthesia, oxygen and diagnostic materials in addition to X-rays and dialysis costs among others.
  • Most policies have an Annual Health Check up available for each member under the policy.
Some of the Advantages include:
  • Most organisations use this as an Employee Benefit (EB) policy to retain and reward employees. This is a standard policy available with most companies to protect their employee workforce., which becomes more efficient and productive if they have a protection against any financial outgo in the case of a health/accidental emergency.
  • It also provides a supplemental health cover for employees (and families) who already have an family / individual health insurance policy on their own
  • A Group health insurance plan is cheaper (usually 25-30%) than individual health plans because the pricing is done for a larger group and hence group discount is offered.
  • Many Benefits like, pre-existing medical conditions coverage, day care treatment, baby day one cover etc are offered under Group Health plans. Even benefits like Maternity come with an enhanced coverage apart from a wider range of disease covers.
  • In most cases, employees are not denied health coverage based on their age or past medical history because they are part of a large risk/group.
  • Some companies allow employees to not only cover their dependant family, but also their parents and parents in law – this allows relatively older persons to enjoy a comprehensive cover at a competitive premium.
Some of the limitations are:
  • The employee will remain covered under the Group Health policy only as long as they are employed by the organisation. This could mean that they have no coverage when in between jobs and the coverages can be different between both organisations.
  • Most group health insurance policies may offer limited coverage owing to sub-limits. An employee, therefore, may not have a full coverage as enjoyed in an Individual policy, which rarely has sub limits.
  • Employees may not always enjoy the standard coverage every year. Companies may reduce/modify the health insurance cover at their discretion depending on the loss ratios of the policy. Alternately the employer could ask the employee to bear a part of the premium to retain the original coverage – this is a financial commitment for the employee.
  • The Group policy may become null and void if the employer does not pay the required premium to the insurance company or if an insurer backs out of the contract with the company citing adverse loss ratios.
  • Since it is a Group policy, while there is a benefit of a reduced premium, there could be a premium/coverage impact for an employee who has never claimed under the policy as well, because of claims made by other members in the group – this will not be the case in an Individual policy.
The standard coverages under a Group Health policy are below:
  • In-patient treatment (Cashless) including room rent, ICU, nursing, medicines drugs & consumables covered without as per the policy terms and conditions upto the Sum insured mentioned on the policy. Covered expenses include:
    • Room, Boarding expenses
    • Nursing expenses
    • Fees of surgeon, anesthetist, physician, consultants, specialists
    • Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, medicines, drugs, diagnostic materials, X-ray, Dialysis, chemotherapy, Radio therapy, cost of pace maker, Artificial limbs, cost or organs and similar expenses.
  • Pre and Post Hospitalization medical expenses: Medical expenses incurred normally upto 30 days immediately before hospitalization and normally upto 60 days immediately post hospitalization remain covered. The coverage period can be extended by submitting relevant documents to the insurer at least 5 days before the Hospitalisation.
  • Maternity + Baby Day 1 cover : coverage for birth of an infant both under Normal or Caesarean deliveries. Infant is a member from Day 1 unlike Retail policies where infants are covered only from Day 91.
  • Day Care Procedures: Most policies covers medical expenses for 120-150 different day care treatments which do not require 24 hours hospitalization
  • Domiciliary Treatment: The policy also covers for the medical expenses incurred for availing medical treatment at home on the advice of the attending Medical Practitioner which would otherwise have required Hospitalisation.
  • Organ Donor: The policy covers Medical Expenses on harvesting the organ from the donor for organ transplantation.
  • Dental Treatment (in case of Accident): The insurance company will reimburse Medical Expenses of any necessary dental treatment from a Dentist provided that the Dental treatment is required as a result of an Accident. Maximum liability shall be limited to the amount specified in the Schedule of Benefits.
  • Ambulance Charges - In most cases the ambulance charges are paid by the policy and the policy holder usually doesn't have to bear the same
  • Cover for Pre-existing Diseases from Policy Inception – Individual Health insurance policies have the option of covering pre-existing diseases after 3 or 4 years of continuously renewing the policy without any break in period, i.e. if someone has hypertension, then after completion of 3 or 4 years of continuous renewal with the same insurer (depending on the plan offered and his age), any hospitalisation due to hypertension will also be covered)… but under a Group Health Policy, this waiting period is entirely waived off in most cases.
Some of exclusions that all the plans under this category have are below; please refer to the respective insurance company websites/policy terms and conditions for the entire list of exclusions:
  • Waiting Periods – Insurers not liable for any treatment which begins during waiting periods except if any Insured Person suffers an Accident.
  • Pre-existing Conditions d) We will not make any payment for any claim in respect of any Insured Person directly or indirectly for, caused by, arising from or in any way attributable to any Pre-existing Condition or any complication arising from the same, unless expressly stated to the contrary in this Policy.
  • War or any act of war, invasion, act of foreign enemy, war like operations (whether war be declared or not or caused during service in the armed forces of any country), civil war, public defence, rebellion, revolution, insurrection, military or usurped acts, nuclear weapons, materials, chemical and biological weapons, radiation of any kind.
  • Any Insured Person committing or attempting to commit a breach of law with criminal intent, or intentional self injury or attempted suicide while sane or insane.
  • Treatment of Obesity and any weight control program,
  • Psychiatric or mental disorders (including mental health treatments), Parkinson and Alzheimer’s disease ; general debility or exhaustion (“run-down condition”) ,congenital internal or external diseases (known / unknown), defects or anomalies, genetic disorders; stem cell implantation/ therapy or surgery, or growth hormone therapy, sleep apnoea. vii) Venereal disease, sexually transmitted disease or illness; “AIDS” (Acquired Immune Deficiency Syndrome) and/or infection with HIV (Human immunodeficiency virus) including but not limited to conditions related to or arising out of HIV/AIDS such as ARC (AIDS related complex), Lymphomas in brain, Kaposi’s sarcoma, tuberculosis.
  • Sterility, treatment whether to effect or to treat infertility, any fertility, sub-fertility or assisted conception procedure, surrogate or vicarious pregnancy, birth control, contraceptive supplies or services and complications arising therefrom.
  • Dental treatment and surgery of any kind, other than arising out of an accident and requiring Hospitalisation.
  • Plastic surgery or cosmetic surgery unless necessary as a part of medically necessary treatment certified by the attending Medical Practitioner for reconstruction following an Accident Cancer & Burns.
  • Any non-allopathic treatment.
  • All preventive care, vaccination including inoculation and immunisations (except in case of post-bite treatment) unless certified to be required by the attending Medical Practitioner as part of in-patient treatment as a direct consequence of an otherwise covered claim ; any physical, psychiatric or psychological examinations or testing; enteral feedings (infusion formulae via a tube into the upper gastrointestinal tract) and other nutritional and electrolyte supplements, unless certified to be required by the attending Medical Practitioner as a direct consequence of an otherwise covered claim.
  • Treatment and associated expenses for alopecia, baldness, wigs, or toupees, medical supplies including elastic stockings, diabetic test strips, and similar products.
  • Artificial limbs, crutches or any other external Aids & Appliance and/or device used for diagnosis or treatment (except when used intra-operatively).
The process is very similar to the Retail Health insurance claim process, which are:
  • Contact the health insurer /TPA (depending on the insurer) in order to file a claim as soon as possible by calling the toll-free number available on the Medical Card or policy document
  • The call centre representative registers a claim and informs the insured about the claim process and all the documents required for reimbursement.
  • If it is a cashless claim, then the insurer/TPA arranges for a Guarantee of Payment (GOP) to the hospital to ensure the treatment is commenced – one must note that the Cashless treatment will only be available at the network hospitals of the insurance company. Treatment at non network hospitals will be treated as a reimbursement claim.
  • The insured can download the claim form from the website of the insurance provider, duuly fill and sign the claim form and submit it to the insurer/TPA.
  • Attach all the required supporting documents with the form like original bills etc if the claim is a reimbursement claim and send the claim form with all the documents to the specific address of the insurance provider.
  • In case of a Cashless claim, the insured will need to settle the deductible / other incidental expenses (not covered under the policy) with the hospital directly.
Group Health insurance is a comprehensive cover that can be bought for large as well as small groups. The premium per lac of sum insured differs from group to group and the factors influencing the discount offered for the GMC policy are:
  • Size of the group
  • Occupation of the insured members – which industry? (IT industry employee group will receive a better rating than manufacturing)
  • Benefits + Add On offered under the policy including specific conditions like Pre Ex Cover, Maternity, Domiciliary Treatment, Day Care coverage etc
  • Sum Insureds of the insured members
    • Graded Sum Insured for each category of employees
    • Flat Sum Insured for all employees of the company
  • Loss history in earlier years for the organization
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