Frequently asked questions
Group Health Insurance
How is Group Health Insurance beneficial to an organisation?
Helps to reduce company’s liability and risk
Great employee retention tool
Improves employee health and wellness
Covers employees regardless of medical conditions
No medical screening
How is Group Health Insurance better than 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:
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?
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?
How will the premium for next year be determined?
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?
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.