Group Health Insurance Policy | Group Mediclaim Policy – Definition, Coverage, Exclusions, Features, Add-On Covers, Benefits, Waiting Periods, Cost, Companies, Claim Process, Quotes

What is a Group Health Insurance Policy? – Definition

A Group Health Insurance Policy, also known as a Group Mediclaim Policy, is a type of Health Insurance Policy which reimburses the employees for the hospitalisation expenses incurred by the employees during the year. A Group Health Insurance Plan covers a group of people under a common Health Insurance Plan. Usually, a company purchases Group Health Insurance Policy for employees.

What does a Group Health Insurance Policy cover?

A Group Health Insurance Policy provides the following Coverages

1. Hospitalisation Expenses: A Group Medical Insurance Policy offers coverage for Hospitalisation Expenses if the Insured Person is hospitalized for more than 24 hours for any injury or illness.
2. Coverage for Pre and Post-Hospitalisation Expenses: Most Corporate Health Insurance Policies provide coverage for Pre and Post-Hospitalisation Expenses for 30 and 60 days respectively.
3. Pre-Existing Diseases: Group Health Insurance Policies provide coverage for Pre-Existing Diseases from 1st Day without any Waiting Period.
4. Coverage for Daycare Procedures: Group Mediclaim Policies also provide coverage for Daycare Procedures which do not require hospitalisation of more than 24 hours.
5. Maternity Coverage: Group Health Insurance Policies also provide coverage for Maternity Expenses with a Sub Limit without any waiting period.
6. New-Born Baby Covered from Day 1: Corporate Health Insurance Policies also have an option to cover New-Born Babies from Day 1 under the Policy.

What is not covered under a Group Health Insurance Policy?

A Group Health Insurance Policy does not cover the following:

1. Coverage for OPD Expenses: A Corporate Health Insurance Policy does not provide coverage for OPD (Out-Patient Department) Treatments though OPD Coverage can be opted for by paying an additional premium.
2. Injuries/Illness caused under influence of alcohol/drugs: A Group Health Insurance Policy does not provide coverage for illnesses or injuries that are caused due to use of intoxicating drugs and/or alcohol.
3. Investigation & Evaluation Expenses: Coverage for expenses related to any admission primarily for diagnostics and evaluation purposes are excluded under a Group Health Insurance Policy.
4. Rest Cure, Rehabilitation and Respite Care: Expenses related to any admission primarily for enforced bed rest and not for receiving treatment are not covered under a Group Health Insurance Policy
5. Cosmetic or Plastic Surgery: Expenses for cosmetic or plastic surgery or any treatment to change appearance are not covered under a Group Medical Insurance Policy
6. Hazardous or Adventure Sports: Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports such as para-jumping, rock climbing, mountaineering, rafting are not covered under a Corporate Health Insurance Policy

What are the Key Features of a Group Health Insurance Policy?

A Group Health Insurance Policy offers various features depending on the Plan selected by the employer. Some common features of a Group Health Insurance Policy are as follows:

1. Cover for Hospitalisation Expenses: All Group Health Insurance Policies offer cover for hospitalisation expenses incurred by the employees during their treatment.
2. Cover for Pre and Post-Hospitalisation Expenses: In addition to cover for Hospitalisation expenses, most Group Mediclaim Insurance Policy for Employees will provide cover for Pre and Post-Hospitalisaiton expenses, usually for 30 days and 60 days respectively.
3. Room Rent Limit: Group Health Insurance Plans will specify a room rent limit (for eg: 1% and 2% of Sum Insured for Normal and ICU Rooms). The Policy will thus pay the room rent only upto the limit specified. You can opt for a Group Health Insurance Plan with no room rent capping as well.
4. Maternity Cover and New-Born Baby Cover: Some Group Health Insurance Policies also provide coverage for delivery expenses as well as expenses incurred on new-born baby if this feature is opted for.
5. Pre-Existing Diseases Cover: Most Group Health Insurance Policy will provide cover for Pre-Existing Diseases without any waiting period. This is a big advantage.
6. Domiciliary Hospitalisation Cover: Some Group Health Insurance Plans offer benefit of Domiciliary Hospitalisation provides reimbursement for treatment availed at home if the Insured Person is unable to get hospitalised.
7. Day Care Procedures: Most Group Health Insurance plans have a list of Day Care Procedures which are covered. Day Care Procedures are procedures which do not require hospitalization
8. Cashless Hospitalisation: Most Group Mediclaim Insurance Policy for employees have a network of cashless hospitals where the Insured can avail treatment without paying treatment expenses from out of their own pocket. The Insurance companies will directly reimburse the hospitals for the treatment cost in case of Cashless Claims Settlement.

What are the add-on covers available under a Group Health Insurance Policy?

Employers can enhance the coverage under a Group Health Insurance Policy by opting for the following add-on covers:

1. Maternity Coverage: GMC Policies provide the option to provide Maternity Coverage without any waiting periods with a Sub-Limit. This add-on cover is very beneficial for female employees and spouses of male employees.
2. Coverage for Pre-Existing Diseases: Most Individual or Family Floater Health Insurance Policies provide coverage for Pre-Existing Diseases after a Waiting Period of 3-4 years. However, employers can provide coverage for Pre-Exisiting Diseases from Day 1 under Corporate Health Insurance Policies.
3. Coverage for Outpatient Department (OPD) Treatment: Coverage for OPD Treatments is usually excluded under Group Medical Insurance. However, coverage for OPD Treatments can also be provided as an add-on cover under a GMC Policy.
4. Corporate Buffer: There are instances when employees the hospitalisation expenses exceed the Sum Insured provided under the Group Health Insurance Policy. In such a case, employers have an option of approving additional expenses incurred by opting for a Corporate Buffer under the Group Health Insurance Policy.

What are the Benefits of Group Health Insurance Policy for Employers?

A Group Health Insurance Policy offers many benefits for employers as listed below:

1. Group Health Insurance Plans can be customised: The features of a Group Health Insurance Policy can be customised depending on the budget and requirements of the employers.
2. Lower Premiums: The premium for a Group Health Insurance Policy is lower than premium for an Individual Health Insurance Plan for similar benefits and coverage.
3. Tax Savings for Employers: The premiums paid by employers towards a Corporate Health Insurance Policy for employees are a tax-deductible expense for the company. The premiums reduce the taxable profits of the company and hence reduces the tax outgo as well.
4. Employee Retention: Group Health Insurance Plans are an important perk for employees and helps in attracting talented new employees as well as retaining existing ones.

What are the benefits of Group Health Insurance Policy for Employees?

A Group Health Insurance Policy offers many benefits for employees as well:

1. Zero Waiting Period for Pre-Existing Diseases: A big benefit of Group Medical Insurance Policy for employees is that the Policy can cover Pre-Existing Diseases without any waiting periods whereas an Individual Health Insurance Plan has a Waiting Period of 3-4 years for Pre-Existing Disease Coverage.
2. Maternity Coverage without Waiting Periods: Another benefit of a Group Mediclaim Insurance Policy is that it can offer Maternity Coverage without any waiting periods as well.
3. No Need for Medical Checkup: Employees can be covered under a Group Health Insurance Policy without any medical checkup whereas they may need to undergo a Medical Checkup under an Individual Health Insurance Policy.

Does a Group Medical Insurance Policy provide Maternity Benefits?

Yes, Maternity Benefits can be provided with a Sub-Limit of Rs50,000 to Rs1,00,000 a Group Medical Insurance Policy for Employees. The Policy will typically cover delivery expenses, doctor’s visits, and pre and post-natal expenses.

What are Waiting Periods under a Group Health Insurance Policy?

A Group Medical Insurance Policy typically has 4 types of Waiting Periods:

1. First 30 Days Waiting Period refers to the Expenses related to the treatment of any illness within 30 days from the first policy commencement date.
2. Waiting Period for Pre-Existing Diseases refers to the Waiting Period for Pre-Existing Disease before the Policy pays out any claims for hospitalization on account of Pre-Existing Diseases.
3. Waiting Period for Specific Diseases: All Group Health Insurance Policies have a list of specified diseases for which the claims are not paid during the Specified Diseases Waiting Period
4. Waiting Period for Maternity Coverage: Most Group Health Insurance Policies have a Waiting Period of 3-4 years before providing maternity coverage under the Policy. All the above-mentioned waiting periods can be waived off by paying additional premium under the Group Health Insurance Policy.

What is the Pre-Existing Disease Cover in a Group Health Insurance Policy?

Pre-Existing Disease refers to any condition, ailment or injury or disease diagnosed by physician within 48 months prior to the effective date of the Policy issued by the Insurance Company. Group Health Insurance Policies offer coverage for Pre-Existing Disease without any Waiting Period which is a big advantage over regular Health Insurance Policies which have a Waiting period of 36 months to 48 months for Pre-Existing Diseases.

What is Room Rent Limit in a Group Medical Insurance Policy?

Group Health Insurance Plans usually specify a room rent limit as a percentage of Sum Insured (for eg: 1% and 2% of Sum Insured for Normal and ICU Rooms). The Policy will thus pay the Room Rent only upto the limit specified. If the actual rent of room exceeds the room rent limit, then the Policy will apply a deduction for the room rent and a proportionate deduction is applied for all other expenses incurred. For example: Consider an employee insured under a Group Health Insurance Policy with a Sum Insured of Rs2 lakhs and a Room Rent Capping of 1% of Sum Insured per day. This means that the maximum expenses payable towards room rent under the Policy is restricted to Rs2000 per day (1% of 2 lakhs) If the employee gets admitted to a hospital with a room rent of Rs4000 per day, then the Policy will reimburse the employee only Rs2000, that is, 50% (2000/4000) towards the room rent. Additionally, all other expenses such as Doctors Fees, Operation Theatre Charges, will be deducted by 50% by applying a proportionate deduction clause.

What is Co-Payment Clause in a Corporate Health Insurance Policy?

Co-payment Clause means a cost sharing requirement under a Group Health Insurance Policy which states that the Insured Employee will bear a specified percentage of the admissible claims amount. For example: Consider an employee insured under a Group Health Insurance Policy with a Sum Insured of Rs2 lakhs and a Co-Payment of 30% of Claim Amount. This means that if an Employee incurred a Hospitalisation Bill of Rs1 lakh, He will bear 30% of the hospitalisation expense ie, Rs30,000 from his own pocket and Rs70,000 (70%) will be paid by the Insurance Company.

What is a Corporate Buffer in a Group Health Insurance Policy?

A Corporate Buffer is an additional financial pool maintained by the Employer within a Group Health Insurance Plan which acts as a reserve to cover an Employee’s medical expenses in cases where his expenses have exceeded his Sum Insured. For Example, an Employee may have a Sum Insured Limit of Rs2 lakhs but his hospitalisation expenses incurred amount to Rs3 Lakhs. In such a case, the Employer may use the Corporate Buffer provided under a Corporate Health Insurance Policy to cover the additional expenses of Rs1 lakh so that the Employee does not face a financial burden.

What are the minimum number of employees required to purchase a Group Health Insurance Policy?

Most Insurance Companies require a minimum of 50 employees for a Group Health Insurance Policy. Group Health Insurance Policy is also available for small businesses and some Insurance Companies do offer a Group Mediclaim Policy for Employee Size of as little as 15 employees.

How much does a Group Health Insurance Policy Cost?

A Group Health Insurance Policy with a Sum Insured of Rs2 lakhs with No Room Rent Limit and Maternity Benefit of Rs50,000 costs approximately Rs4,000 to Rs5,000 per employee. The Cost of a Group Health Insurance Policy depends on the following factors:

1. Total Number of Lives (Employees and Family Members)
2. Age Distribution of Employees and their Family Members
3. Sum Insured
4. Features of Group Health Insurance Policy
5. Claims Experience in Expiring Policy

Which are the leading Group Health Insurance Companies in India?

The Top Group Health Insurance Companies in India are as follows:

1. SBI General Insurance Company
2. New India Assurance Company
3. ICICI Lombard General Insurance Company
4. Bajaj Allianz General Insurance Company
5. GoDigit General Insurance Company
6. Tata AIG General Insurance Company
7. HDFC Ergo General Insurance Company

Which type of Organisations can purchase a Group Health Insurance Policy?

Group Health Insurance Policies are available for organisations of all types and sizes as listed below:

1. Group Health Insurance Policy for Startups: Start Ups can purchase a Group Health Insurance Policy as a cost-effective way to provide comprehensive Health Insurance Coverage to employees.
2. Group Health Insurance Policy for Small Business: Small Businesses can purchase a Group Health Insurance Policy as a means of retaining and attracting talented employees. A Group Health Insurance Policy for small business is available for as little as 15 employees.
3. Group Health Insurance Policy for Large Enterprises: Group Health Insurance Policies for Large Enterprises are available which provide financial security to the employees and their family members by taking care of their medical expenses.

What are the Tax Benefits of a Group Health Insurance Policy?

The Premiums of a Group Health Insurance Policy are a Tax-Deductible Expense for the Employer who pays the Premium. The Premiums Paid towards the Group Medical Insurance Policy reduce the taxable profits of the Company and hence lower the tax outgo as well. Additionally, the Claim Amount received by employees as part of claims settlement are treated as reimbursement of expenses already incurred by the Policyholder and hence the claim amount is also not taxable.

What is the difference between a Group Health Insurance Policy and an Individual Health Insurance Plan?

1. The main difference between a Group Health Insurance Policy and an Individual Health Insurance Plan is that a Group Health Insurance Policy is purchased by an Employer to insure all his employees under a common Health Insurance Plan while an Individual Health Insurance Policy is purchased by the Individual himself.
2. Group Health Insurance Plans are less expensive an Individual Health Insurance Plans and they offer more comprehensive coverage.
3. Group Health Insurance Policies have no waiting period for Pre-Existing Diseases and Maternity Benefits while Individual Health Insurance Policies have a waiting period of 3-4 years for the same.
4. Group Health Insurance Policies also typically do not require medical checkups of the Insured while an Individual or a Family Floater Health Insurance Policy requires a medical check-up of the Insured Person.

How to Purchase a Group Health Insurance Policy with Qian?

Qian Insurance is a licensed Insurance Broker with tie-ups across a wide range of Group Health Insurance Companies in India. The dedicated team at Qian will assist you in comparing Quotes across multiple Group Health Insurance Companies. You need to share the following information with Qian to purchase a Group Mediclaim Policy:

1. Employee Name
2. Employee Gender
3. Employee Date of Birth and Age
4. Name and Age of Family Members (if family members are covered)
5. Sum Insured required for each employee
6. Features Required in the policy
7. Claims History in the expiring Group Mediclaim Insurance Policy
8. Premium Cheque

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What is the Claims Process in a Group Health Insurance Policy?

The Claim Process in a Group Health Insurance Policy is listed below:

Intimate Insurance Claim to the Insurance Company

You need to intimate the claim to the Group Health Insurance Company by either:

1. Go to the Insurance Company’s Website, Click on Claims and register a claim by providing details like Insured Information, date of hospitalisation, Policy Number etc. The Insurance Company will provide a Claim Intimation number upon successful registration of the Claim.
2. Intimate the Claim to Insurance Broker who will intimate the Claim to the Insurance Company on your behalf

Cashless Claims Settlement Process in a Group Health Insurance Policy

Cashless Claims Settlement allows Insured Employees to receive treatment at network hospitals without paying upfront for medical expenses. The Employee should follow the below mentioned steps in order to avail Cashless Claim Settlement under a Group Health Insurance Policy:

1. Identify Network Hospital: Ensure that the hospital is part of the Group Health Insurer’s network.
2. Show Health Card: Present your Group Health Insurance Card at the Insurance Desk of the Hospital.
3. Pre-Authorization Form: Fill out a Pre-Authorization Claim Form, which the hospital sends to the Group Health Insurance Company for approval.
4. Approval from Insurance Company: The Insurance Company reviews the form and, if the claim is admissible, provides approval for Cashless Treatment.
5. Receive Treatment: The Policyholder avails treatment at the hospital without making any payment.
6. Settlement: The Hospital sends the final bill to the Insurance Company, which settles the bill directly with the hospital, excluding any Non-Covered Expenses or Deductibles, which the Policyholder needs to pay.

Reimbursement Claims Settlement Process in a Health Insurance Policy

Reimbursement Claims Settlement Process involves paying for medical expenses out of pocket and then claiming a Reimbursement from the Group Health Insurance Company. If the Employee chooses a non-network hospital, he will have to opt for Reimbursement Claim Settlement. The Reimbursement Claim Settlement Process is listed below:

1. Receive Treatment: Pay for the treatment at the hospital
2. Collect Documents: Obtain all necessary documents, including bills, receipts, discharge summaries, and medical reports.
3. Submit Claim Form: Fill out the Group Health Insurance Company’s Claim Form and submit it to the Insurance Company along with the necessary documents.
4. Insurance Company Review: The Group Health Insurer will verify the Claim Details, ask for additional documents if required and will approve or reject the Claim.
5. Approval and Payment: The approved Claim Amount gets credited directly to the Bank Account of the Insured.

What are the documents required for a Reimbursement Claim under a Health Insurance Policy?

An Employee would need to provide the following documents to make a claim under a Group Health Insurance Policy:

1. Photo Identification Proof
2. Duly Filled and Signed Claim Form
3. Address Proof
4. Medical Reports
5. Cancelled Cheque of the employee
6. Diagnostic Reports
7. GMC Policy E-Card
8. Doctor Prescriptions
9. Hospital Bills, Pharmacy Bills
10. Discharge Summary

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Get Best Group Health Insurance Policy Quotes with Qian!

A Group Mediclaim Policy for employees provides financial support to the employees and their family members by taking care of their medical expenses. This ultimately boosts the morale of employees resulting in higher productivity. It also helps attract better employees since they are aware that their medical expenses are taken care of with a good Corporate Health Insurance Plan should such a need arise. Thus, a Group Health Insurance Policy is a wise investment that an Employer can make. Qian has an outstanding service record and has worked with corporates across industries to assist them with their Group Mediclaim needs. We have settled more than 98% of the GMC Claims with great satisfaction and fast turnarounds. Qian has tie-ups with 20+ Group Health Insurance Companies in India and you can compare the plans and features from various Group Health Insurers to obtain comprehensive coverage at affordable premiums. We assure you of best Group Health Insurance Quotes and a dedicated claims settlement team for fast claims settlement. If you wish to purchase a Group Health Insurance Policy for your organisation, feel free to reach out to us at insurance@qian.co.in or 📞 022-35134695 . We will get back to you within 24 hours, guaranteed.

FAQS about Group Health Insurance Policy for Employees