As the name suggests, the Group Health Insurance Policy or the Group Mediclaim Policy or the Corporate Health Insurance Policy provides Health Insurance or the Health Coverage to a Group of Members or specific groups like - Employers Employee of an organization, Groups where the premium is to be paid by the Government, Members of a registered service clubs etc. The Group Health Insurance Policy can also be extended to cover Family Members of The Employee (Spouse+ Dependent Children + Dependent Parents). The Group Health Insurance Policy essentially provides cover for in patient hospitalization, maternity benefits, covid cover, day care procedures, accidental hospitalization, critical illnesses etc.
A Group Health Insurance Policy is a customized policy. Therefore, the following features can be added under the group health insurance plan:
An employee is considered as the most important asset in an organization. They are often referred as Internal Customers and if your internal customers are happy, they will do their best to keep the external customer happy. This not only increases the productivity of an employee but also it adds to the profits of the company. A Group Health Insurance Policy is also considered as a perk to join any new organization. The Covid 19 Pandemic too has also led emphasis on having a Health Insurance Policy to take care of every medical emergency.
Therefore, a Group Health Insurance policy can be bought since it benefits both the Employer and the Employee.
The Group Health Insurance policy gets triggered where at least 24 Hours Hospitalization is required for treatment of any disease or ailment. But there are certain ailments where due to Medical Advancements hospitalization may not be required for 24 hrs. such as Cataract Surgery. Such treatments fall under Day Care Procedures and are covered under the policy.
Like we mentioned above that a Group Health Insurance Policy is a customized policy. The Policy covers the following benefits:
The Company will indemnify the Medical Expenses incurred which are reasonable and customary charges that are medically necessary towards In- patient Care Hospitalization of the Insured Member, limited to the Sum Insured Limit as specified in the policy schedule, provided that such Hospitalization is for a minimum period of 24 consecutive hours.
A medical condition that exists before the policy inception. Eg Diabetes, Hypertension etc. In a Group Health Insurance Policy, PED can be covered from Day without any waiting periods and medical examinations.
Many Group Health Insurance Polices covers maternity benefit from Day 1. It covers both normal and c section deliveries. The limit of c section is generally higher than the normal delivery.
A cover for a newborn can be included from Day 1 from his date of birth, under a Group Health Insurance Policy.
Pregnancy care consists of prenatal (before birth) and postpartum (after birth) healthcare for expectant mothers. A Group Health Policy Covers can be extended to cover Pre- Post Natal Expenses as well.
Waiting Period is a period when a certain disease is not covered under the policy and a person must wait for a certain period to pass by (say a waiting period of 1 year for a PED, which means PED will be covered under the group health insurance after one year of completion of the policy). However, the customer has the option to get all the waiting periods waived off under a Group Health Insurance Scheme.
An internal congenital disorder is a condition that is present from birth. Congenital disorders can be inherited or caused by environmental factors.
Medical expenses incurred for covered Hospitalisation expenses, related and prior to 30 Days of Hospitalization.
Medical expenses incurred for covered Hospitalisation expenses, related and post 60 Days of discharge.
In a Group Health Insurance Policy Day Care Procedures means medical treatment which is undertaken under general or local anaesthesia in a Hospital/ Day Care Centre in less than 24 consecutive hours because of technological advancement, and which would have otherwise required a Hospitalization of more than 24 consecutive hours.
The insurance company usually pays a fixed amount, as specified in the Policy Schedule towards 24 hours of In Patient- Hospitalization of an Insured Member.
Medical expenses that are incurred for in-patient treatment under Homeopathy, Ayurveda, Siddha or Unani, are subject to reimbursement.
Corporate Buffer is the amount over and above the individual or the family sum insured. The amount is set aside by the Employer for emergency situations and the decision to use this buffer is solely kept at the discretion of the HR.
Co Payment (usually flat or % of the claim amount) refers to the amount that insured will have to bear from his own pocket.
Room Rent means the amount charged by a hospital towards room and boarding expenses and shall include the associated medical expenses. If the Insured Member is admitted in a Hospital room where the Room Category opted or Room Rent incurred is higher than the eligible Room Category/ Room Rent as specified in the Certificate of Insurance, then, the Insured Member shall bear the ratable proportion of the total Variable Medical Expenses ( including applicable surcharge and taxes thereon) in the proportion of the difference between the Room Rent actually incurred and the Room Rent specified in the Certificate of Insurance or the Room Rent of the entitled Room Category to the Room Rent actually incurred.
An employee can undergo a Health Check up under the Group Health Policy as per terms defined in Health Insurance Policy Schedule. This may be offered complementary or at discounted price by the Insurance Company.
A Group Health Insurance can be extended to cover Psychiatric Treatments. The Insurance Company will indemnify the Insured Member for the Medical Expenses incurred towards psychiatric treatment as defined in the Policy Schedule.
A Group Health Insurance can also be extended to cover Modern Treatment Method. The Insurance Company will indemnify the Insured Member for the Medical Expenses incurred towards treatment done through following modern treatment methods such as Balloon Sinuplasty, Robotic surgeries, Stem cell therapy etc as defined in the Policy Schedule.
The Company will indemnify up to the amount specified in the Policy , for the medically necessary Expenses incurred by the Insured Member in respect of Lasik Surgery provided the power of eye is above +/- 7.5 or as specified in the Policy Schedule.
The Company will indemnify up to the amount specified in the Certificate of Insurance, for the Reasonable and Customary charges necessarily incurred by the Insured Member, for procuring, fitting or hiring instruments, apparatuses or devices which are medically prescribed at the time of discharge as a medical aid such as compression stockings, hearing aids, speaking aids), standard wheelchairs crutches, orthopedic supports /braces/corrective splints, orthotics etc.
A Claim under Group Health Insurance Policy can be availed either through Cashless or Reimbursement Mode.
The following documents are mandatory for filing a reimbursement claim.
Any Claim in respect of any Insured Memberfor, arising out of or directly orindirectly due to any of the following shall not be admissible unless expresslystated to the contrary elsewhere in the Policy:
A Health Insurance policy protects us from the sudden, unexpected costs of hospitalization (or other covered health events, like critical illnesses) which would otherwise make a major dent into household savings. Each of us is exposed to various health hazards and a medical emergency can strike anyone of us without any warning. In addition, Healthcare is increasingly expensive, with technological advances, new procedures and more effective medicines that have also driven up the costs of healthcare. While these high treatment expenses may be beyond the reach of many, taking the security of health insurance is much more affordable.
Health Insurance is a type of Insurance that covers your Medical Expenses. It can be used where there is at least 24 hours hospitalisation and listed day care procedures where 24 hours hospitalization not mandatory.
Hospitalization or In-patient Care means treatment for which the patient has to stay in a hospital for more than 24 hoursfor a covered event for treatment of certain illness. There are 2 types of Hospitalization – Planned & Unplanned.
Planned hospitalisation is when you have enough time on hand to decide the hospital you want to get admitted depending upon the nature of the illness. The most essential part is to make the Insurance Company aware of the nature of illness and get approval for the same from the TPA in advance before admission.
Unplanned hospitalization or an emergency hospitalization means when a patient needs emergency medical attention which cannot be managed on an outpatient basis. The insured can still avail a cashless service by informing the TPA or the insurance company.
Insurance Co. have done tie up arrangements with many of the Hospitals across India. If an employee gets admitted to any network hospital of Insurance Company, they can avail cashless facility by showing their TPA Member Id Card.
Another mode of Claim Settlement is Reimbursement, whereby the insured settles the expenses, incurred towards his hospitalisation, directly with the hospital and later files for a reimbursement claim with the TPA or the insurance company.
Normally, the reimbursement claim can be filed with the TPA or the Insurance Company within 15/ 30 days from date of discharge.
In case the hospital is not empanelled with the Insurance Company, you can pay to the hospital towards the hospitalisation expenses and file for a reimbursement claim from your Insurance Company
The employee can file unlimited claims up to his sum insured limits. Once his sum insured gets exhausted, he will be not able to file any further claims.
No, OPD & Day Care are not same. Day Care Treatments (which are listed by Insurance Company) are covered under Health Policy. However, OPD is an exclusion under the policy but can be included on payment of extra premium under a Group Health Policy.
Cashless Facility can be availed only at the Network Hospital which has an tie up with the Insurance Co. If a hospital empanelled with the insurance company, then the insured will have to bear the hospitalization expenses and file for a reimbursement claim from his insurance company. Hospital Network List for each insurer varies, hence this needs to be checked with the insurer beforehand in case of a planned admission.
Health Policy is applicable only in India. In case an employee wants to take a policy outside Indian borders, then Travel policy must be taken which is a different product all together.
The Group Health Policy is generally a customised policy where features can be added basis the clients’ requirements. Pre-Existing Diseases can be from Day 1 in Group Health Insurance Policy. By pre-existing disease, we mean, any ailment which is prior to policy inception, an employee may or may not be aware about it.
Cashless Hospitalisation – Only Insurance Mediclaim Card, Govt ID Proof, past medical records of the ailment employee is suffering from is required.
Reimbursement Claim Form, Test Reports (both X Rays & Written Reports) , Medicine Bills, Discharge Summary , Cheque Copy , Doctor Prescription , Hospital Registration Certificate etc (all documents in original).
No, any treatment done under Blacklisted/Cautious Hospital will not be payable under the policy. This hospital list keeps on changing for every insurer, hence please check the same with the insurer before going for a hospitalisation.
Room Rent impacts the Hospitalisation Bill. The higher the Room Rent than what is defined in your policy, more will be the % of your share in settlement of the hospital bill. Hence before Hospitalisation, we recommend checking your Room Rent Limit defined under the policy and try opting for a room within your limit. Please refrain from opting for a room higher than your defined limit. If an employee opts for a higher room rent, then the proportionate increase will be deducted on the entire bill and not only on the Room Rent part.
A Health Policy Covers all diagnostic tests which are connected to 24 hours hospitalisation. Any other tests which are not connected to ailment for which patient is admitted or prescribed by Doctor in OPD individually are not payable
Sum Insured can be changed only if the employee gets promoted during the policy period. Otherwise, it is not possible to change the sum insured during the tenure of a Group Mediclaim/ Health Policy.
Medical check-up is not required in any of the Group Mediclaim or a Group Health Policy.
Usually, Maternity Expenses can be Claimed only for first 2 Living Children or first 2 deliveries only subject to the policy terms and condition.
Yes, if a person is Covid Positive and treatment is not possible in-home isolation, hospitalisation in context to Covid Treatment is payable up to his Sum Insured limit only.
Addition of dependent is allowed in the mid of year but only for Newly Wedded Spouse or new born baby under subject to the policy term and condition.
For Cashless TAT – 2 to 4 hours and for Reimbursement Claim TAT is 15 days.