• 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.