How well do you know your corporate health insurance benefits? - #01


Corporate Health Insurance benefits you should know

A corporate health insurance is a type of insurance, also known as group health insurance, that covers the entire pool of employees, and sometimes their family members as well, in professional organizations against any unforeseen medical emergencies. While the corporate health insurance usually offers a low sum insured, it comes with a spectrum of benefits that the employees aren’t always aware of. You probably are covered under one of these as well, but ask yourself – how well do you know your corporate health insurance benefits?


Family Coverage

A corporate health insurance plan may have either type of family coverage:

  • Employee only

  • Employee and Spouse

  • Employee, Spouse, Children

  • Employee, Spouse, Children (if married) & Employee, Parents (if unmarried)

  • Employee, Spouse, Children, Parents/Parents-in-law

Corporate health insurance allows an easy coverage of parents without pre-policy medical check-ups, which otherwise is difficult due to their age and medical conditions.


Sum Insured

  • Sum insured is the total value of coverage for a year that your insurance company​ can pay in case you are hospitalized (single or multiple claims in a year)

  • Most corporates today choose sum insured in the range of Rs. 2 lacs to 5 lacs (Max limit: Rs. 20 lacs)

  • Such sum insured is by default on a family floater basis i.e. sum insured for all family members combined

Insurance Company

  • The choice of insurance company and TPA influences the claim settlement experience. Some insurance companies have in-house claim settlement teams.

  • Insurance companies settle claims on cashless and reimbursement basis.

  • The size of network hospitals list of the insurer determines the ease of access to cashless hospitalization. Any insurer with 6,000+ empaneled hospitals can be construed to be a good choice.

  • Another important metric is the Claim Settlement Ratio of the insurance company which is the number of claims settled ÷ number of claims received. Corporate health insurance enjoys the advantage of superior CSR (generally 95%+).

TPA

  • TPA or Third-Party Administrator is defined as an organization that handles the insurance claims, processing, and reporting of any health benefits plan

  • All public sector insurance companies and many private companies appoint an external TPA for claim administration

  • Few large private companies like ICICI Lombard, Bajaj Allianz, Care Health have inhoused the TPA function and are able to drive a better claim settlement experience

More Features: While most employees are aware of the headline benefits, but are you aware of these sub-limits under your policy?

  • Room Rent limit- a capping on the amount you can claim towards room rent per day in a hospital.

  • Disease capping- a clause that restricts the maximum payout for specific diseases.

  • Co-payment or % Sub-limits- a clause that mandates you to pay a certain percentage of the total expense of hospitalization or treatment.

  • Waiting period- the amount of time one needs to wait for, after the start of the policy, to be able to use its full benefits.

  • Pre & Post hospitalization coverages- medical costs incurred before getting admitted to and post-discharge from the hospital

These limits may lead to a surprise at time of claim settlement. Look out for our next article to know more about these features of a corporate health insurance policy.


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