How is Group Health Insurance beneficial to an organisation?

Some of the key benefits include:

• Helps to reduce company’s liability and risk
• Great employee retention tool
• Improves employee health and wellness
• Covers employees regardless of medical conditions
• Customized features
• No medical screening

How is Group Health Insurance better than Personal Health Insurance?

Group Health Insurance has following advantages over Personal Health Insurance:

• 30-50% cheaper than personal health insurance
• Coverage of pre-existing medical conditions from Day 1 – no medical screening, no rejections, no waiting period
• Similarly, coverage of specific or named diseases from Day 1 without any waiting period
• Coverage of maternity expenses
• Coverage of new born baby from Day 1
• Inclusion of parents under the family definition
• Superior claim settlement ratio

What are pre-existing diseases?

Pre-existing diseases (PED) are such which are already known to the patient at the time of policy inception. Eg. Hypertension, Diabetes, Asthama, Thyroid, High Cholesterol etc. For any treatments that are linked to these PED conditions disclosed by the patient, the same would be subject to waiting period unless waived off. (Eg. Angioplasty for a hypertension patient).

What are specific diseases?

Specific diseases (SD) are slow moving diseases where patients undergo planned surgeries such as removal of kidney stones and cataract. In many cases, the patient is even unaware that he is suffering from such health conditions and it does not bother him in short term unless the health condition aggravates. Unless waived off, these specific diseases are subject to blanket waiting period of 2 years regardless of patient aware/unaware of these conditions. An indicative list of such diseases are as follows: 1) Knee/Joint Replacement Surgery 2) Sinus, Tonsils 3) Kidney Stones 4) Cataract Surgery 5) Skin Tumours 6) Hysterectomy 7) Fissures 8) Hernia 9) Varicose Veins 10) Genetic Disorders

What is room rent restriction?

The room rent restriction is expressed in terms of percentage of Sum Insured (SI) per day for Normal Rooms and ICU. Let's take an example - say if sum insured (SI) is Rs. 3 lacs and room rent limit is 2% of SI per day for Normal & 4% of SI per day for ICU. If any employee is admitted to a hospital where per day normal room rent charges are Rs.8K whereas allowable room rent limit under the policy is Rs. 6K (2% of 3 lacs), then not just the room rent but the entire hospital bill (excluding medical consumables, diagnostic fees, medical devices) will be settled on a pro-rata basis in the ratio of allowable room rent (6K) to actual room rent (8K) i.e. 75%. This means 25% of the hospitalization bill would need to be borne by the patient out-of-pocket.

Are there any hidden/additional charges?

Generally, the hidden conditions in an insurance policy are in three forms:

• Sub-limits: These are typically in the form of room rent limits, disease capping and waiting period for pre-existing diseases. It is important to choose a policy without these sub-limits.
• Medical consumables: These are all medical costs incidental to treatments of the patient such as diagnostic tests, gloves, surgicals, injections etc. These are generally covered as per reasonable and customary limits set by the insurer (standard charges for the specific provider and consistent with the prevailing charges in the geographical area). If the hospital overcharges for such medical consumables, then the insurer will only settle as per reasonable and customary limits.
• Non-medical consumables: These are non-medical expenses in the nature of hospital admission, discharge, administration, registration, documentation and filing charges. In addition, it includes other incidental expenses such as telephone, internet, food, cosmetics, hygiene products, guest service and similar supplies. IRDA has standardized the definition of non-medical consumables and prescribed a list of 68 items under the definition. These are never covered by any insurer and constitute 5-10% of hospital bills and need to be paid out-of-pocket.

What happens in case of additions/deletions?

For additions during the year, a pro-rata premium is charged for the residual period of the policy. For deletions, a pro-rata refund is credited to the employer's ledger account with the insurer. This balance is used to adjust the cases of additions, if any. For any deficit that remains post adjustment, the balance needs to be settled instantly by the employer for processing of the additions. Surplus if any in the ledger account will be refunded at the end of the year.

How will the premium for next year be determined?

The premium for next year will be a function of claims admitted in the current year. The insurer’s price algorithms will analyze the claim amounts, claim type, probability of recurrence and risk factor of the group profile. As per market experience, only 3-4% policyholders make a claim under self-only coverages while 7-8% policyholders make a claim under self-spouse-children coverages with 90% claims being under Rs. 1 lac.
Note unlike a retail policy, there is no retention benefit if the corporate continues with the same insurer. So the next year's quote from the current insurer will be equally competitive to avoid any risk of losing business to an alternate insurer.

Are employees with pre-existing conditions such as blood pressure, diabetes, asthma, etc. covered?

Yes, such cases are covered from Day 1 without any waiting period or medical screening. This is one of the biggest advantages of group health insurance.

Are COVID-19 treatments covered?

Yes, COVID-19 treatments are covered from Day 1 without any waiting period. If home hospitalization is covered under the policy, then even home treatments for COVID-19 are covered else only in-patient hospitalization with pre and post hospitalization expenses incl. doctor consultations, lab tests, medicines shall be covered.

Can we opt to cover family members?

Yes, there are four categories of family coverages under group health insurance:

• Self only
• Self + Spouse
• Self + Spouse + 2 Children (upto 25 years)
• Self + Spouse + 2 Children (upto 25 years) + 2 Parents / Parents-in-law (upto 80 years)

Is there any minimum requirement to take group health insurance?

A minimum group of 10 employees is required in order to avail group health insurance.

Can we take policy for specific employees?

No, group health insurance by default requires all employees who are on company payroll to be covered under the policy. However, there is an option to choose different sum insured based on employee grades.
Note if a section of the employees are covered under Employee State Insurance (ESI), then the employer has an option to specifically buy the cover for all non-ESI employees to avoid duplication of health covers.

Can we take different sum insured for different grades of employees?

Yes, there is an option to choose different sum insured based on employee grades.

What is the age limit of employees under group health insurance?

The maximum age limit is 80 years while there is no minimum age limit.