Group Health Insurance

What is Group Health Insurance?

Group Health Insurance is an insurance policy tailored for a collective of employees within the same company. This plan encompasses an extensive array of medical expenses, from ambulance services, medications, to specialist consultations. Under this policy, the coverage begins the moment an employee joins the company and persists until their departure. Premiums for these group medical insurance plans are borne by the employer. Such plans are typically procured by companies or organizations as a value-added benefit, ensuring medical coverage for their workforce.

Features of Group Health Insurance Plan

The primary intent of this policy is to grant medical benefits to employees. Extended coverage can also be provided for spouses, children, and dependent parents as additional beneficiaries.
Many plans accommodate pre-existing health conditions and maternity care provisions.
Cashless hospitalization is generally facilitated at affiliated network hospitals.
Provisions exist in some plans to compensate specialists and various medical practitioners for post-hospitalization consultations.
A distinctive feature of group health insurance, as opposed to individual health plans, is the lack of a prerequisite for medical screenings.

Why do you need Group Health Insurance?
Corporate health insurance stands as a pivotal strategy to attract and retain premier talent within your organization. An exhaustive health insurance policy alleviates the burden of hefty hospital bills, bestowing peace of mind upon employees. This not only curtails turnover but also fosters a nurturing workplace environment.

What will a Group Health Insurance Policy cover?

Coverage for pre-existing diseases

A pre-existing disease is a medical condition or illness that an individual already has before seeking insurance coverage. Group health insurance coverage starts to cover pre-existing diseases from the very day an employee joins the company. Usually, there is no waiting period as such for any pre-existing disease.

Maternity coverage

Group Health Insurance policy offers financial protection for childbirth-related expenses for both C-sections and normal deliveries. Usually, there is no waiting period for maternity coverage in these policies. However, some providers may have a 9-month waiting period. Expenses covered may include hospitalization for childbirth, room charges, nursing fees, operation theater charges, and other medical services specific to the delivery. The policy may have a specified sub-limit for such expenses. Group Health Insurance policies often cover pre and postnatal care expenses as well.

Newborn baby coverage

New-born babies are covered from the moment they are born. The coverage includes medical expenses incurred for the baby during the coverage period. This can include hospitalization expenses, consultations with pediatricians, vaccinations, diagnostic tests, medications, and any necessary medical treatments related to the baby's health. However, such expenses may have certain limits and sub-limits.

Ambulance costs

The insured can claim the cost of a road ambulance to travel to the hospital or from the hospital to the place of residence under this cover. The policy may cover both emergency and non-emergency ambulance services. The policy specifies the criteria for availing ambulance coverage, which can include the distance of transportation, the severity of the medical condition, and the recommendation of a medical professional. A defined coverage limit is usually set for ambulance expenses.

Pre and post-hospitalization expenses

The policy specifies a predefined period of pre and post-hospitalization coverage, typically ranging from 30 to 90 days before and after the hospitalization. The coverage may include the costs related to diagnostic tests, consultations, medications, and other medical services directly linked to the hospitalization, within this specified period. It may also include follow-up consultations, rehabilitation services, and other necessary treatments after hospitalization.

Expenses for domiciliary and daycare

Domiciliary coverage refers to the reimbursement of medical expenses incurred for treatment received at home when hospitalization is either not possible or not medically necessary. The policy specifies the criteria for availing of such coverage, which may include the need for continuous medical supervision and the recommendation of a medical professional. Similarly, daycare treatment refers to medical operations that do not require 24-hour hospitalization. These include cataract surgery, tonsillitis surgery, and others.

Medical practitioners and specialist’s fees

This policy offers financial protection for the fees charged by doctors and specialists for in-patient hospitalization, outpatient consultations, and treatments. However, the policy may specify a maximum limit on the coverage for such fees.

Most Popular Extensions :
Upon purchasing group health insurance, employers can opt for enhanced coverages:

Immediate maternity cover, devoid of waiting periods.
Newborn coverage within the maternity limit.
Optional OPD (Outpatient Department) coverage.
A corporate buffer, in case an employee's existing sum assured is depleted and further funds are needed.

What's not covered?

Certain standard exclusions exist :

Some policies might exclude employee's parents, but extensions are available for parent coverage.
Non-allopathic treatments like homeopathy or ayurveda aren't covered.
The policy's validity is restricted to the employee's tenure with the company.
Treatments for AIDS, and congenital defect-related conditions usually aren't covered.
Alcohol or drug abuse-linked complications and illnesses aren't included.

Who needs a Group Health Insurance Policy?

Business owners with an official registration can consider offering health insurance to their employees. Regardless of the business size, from startups to large enterprises, ensuring your team has health coverage promotes well-being and health security for all members of the organization.

Investing in a group personal accident insurance policy for your team can accelerate growth by both attracting and retaining top-notch talent.
Group health insurance aids SME employees in navigating healthcare expenses and obtaining quality healthcare services. SMEs have the opportunity to purchase tailored healthcare plans and simultaneously enjoy tax benefits.
It's customary for large organizations to extend group health insurance to their employees. Such policies offer uniform coverage to all members, independent of age, gender, or hierarchical position. Here at BimaKavach, we present a spectrum of benefits tailored for sizable enterprises.

FAQs

Is group health insurance for employees mandatory?

On 15 April 2020, the Ministry of Home Affairs issued an order (No. 40-3/2020-DM-I (A)), where point no. 5 in the associated Standard Operating Procedure (SOP) mandates medical insurance for all employees.

What determines the premium of group health insurance?

Premiums in group health insurance are derived from several factors assessing the risk of covering a group. These factors typically include:

Number of individuals in the group
Gender distribution within the group
Average age of group members
Family composition of the employees
The occupation or industry nature of the group members
Specified coverage limits for the group policy
Chosen additional benefits

What is group insurance room rent capping?

Group mediclaim policies often establish sub-limits or caps for diverse hospital expenses, including room rent. Claim admissibility might differ based on the room type an insured selects during hospitalization. Policyholders are advised to adhere to the room rent limit to facilitate smooth claim admissibility.

How does group health insurance offer maternity benefits?

Group health insurance generally provides maternity benefits as follows:

Pre and post-natal expenses: Coverage often extends to 60 days before and 90 days post-hospitalization.
In-patient hospitalization: Hospitalization costs, such as doctor consultation fees, surgeries, and room rent, are covered.
Type of delivery: Both delivery types (natural and C-section) are included.
Vaccination costs: Expenses for baby vaccinations post-birth, aligned with the WHO schedule, are covered

Lawful pregnancy termination: Costs related to legal terminations fall under the maternity coverage. It's crucial to review the insurance policy comprehensively to grasp the exact maternity benefits offered.

Do we require a pre-existing disease waiver?

A pre-existing disease waiver within group health insurance can be invaluable. It ensures coverage for treatments and costs related to pre-existing conditions from the policy's outset, devoid of specific waiting periods or exclusions. Such a waiver guarantees immediate medical treatment and services access for any pre-existing conditions.

How do you file a cashless claim for Group Health Insurance?

To initiate a cashless claim in group health insurance, adhere to the steps below:

Complete a pre-authorization form at the TPA counter during admission and notify your insurance company beforehand for ultimate approval.
Present necessary documents at the TPA counter, such as the cashless healthcare card from your insurer and KYC document copies for verification.
The insurance company, upon reviewing these documents, provides cashless approval for your hospitalization and retains all treatment-related documentation.
It's prudent to procure a personal copy of these documents for your records. Retain all medical reports, test outcomes, discharge summaries, etc., as they are pivotal for seamless claim processing and future referencing.
Cashless hospitalization enables the insurer to bear your treatment costs, with the policyholder accountable for any charges not covered per insurance guidelines.