Group Health Insurance

As the name suggests, the Group Health Insurance Policy or the Group Mediclaim Policy or the Corporate Health Insurance Policy provides Health Insurance or the Health Coverage to a Group of Members or specific groups like - Employers Employee of an organization, Groups where the premium is to be paid by the Government, Members of a registered service clubs etc. The Group Health Insurance Policy can also be extended to cover Family Members of The Employee (Spouse+ Dependent Children + Dependent Parents). The Group Health Insurance Policy essentially provides cover for in patient hospitalization, maternity benefits, covid cover, day care procedures, accidental hospitalization, critical illnesses etc.

A Group Health Insurance Policy is a customized policy. Therefore, the following features can be added under the group health insurance plan:

• Pre-Existing Diseases from Day 1.
• Maternity Benefit.
• Baby Day Cover from Day 1.
• Waiver of Waiting Periods.
• High Room Rent Category.
• Corporate Buffer.
• Out-Patient Expenses.

Benefits of Group Health Insurance

Policy An employee is considered as the most important asset in an organization. They are often referred as Internal Customers and if your internal customers are happy, they will do their best to keep the external customer happy. This not only increases the productivity of an employee but also it adds to the profits of the company. A Group Health Insurance Policy is also considered as a perk to join any new organization. The Covid 19 Pandemic too has also led emphasis on having a Health Insurance Policy to take care of every medical emergency.

Therefore, a Group Health Insurance policy can be bought since it benefits both the Employer and the Employee.

When does the Group Health Insurance Policy Get Triggered?

The Group Health Insurance policy gets triggered where at least 24 Hours Hospitalization is required for treatment of any disease or ailment. But there are certain ailments where due to Medical Advancements hospitalization may not be required for 24 hrs. such as Cataract Surgery. Such treatments fall under Day Care Procedures and are covered under the policy.

Features of a Group Health Insurance Policy.

Like we mentioned above that a Group Health Insurance Policy is a customized policy. The Policy covers the following benefits

1. In patient Treatment
   The Company will indemnify the Medical Expenses incurred which are reasonable and customary charges that are medically necessary towards In- patient Care Hospitalization of the Insured Member, limited to the Sum Insured Limit as specified in the policy schedule, provided that such Hospitalization is for a minimum period of 24 consecutive hours.
2. PED Diseases
   A medical condition that exists before the policy inception. Eg Diabetes, Hypertension etc. In a Group Health Insurance Policy, PED can be covered from Day without any waiting periods and medical examinations.
3. Maternity Benefits
   Many Group Health Insurance Polices covers maternity benefit from Day 1. It covers both normal and c section deliveries. The limit of c section is generally higher than the normal delivery.
4. Baby Cover from Day 1
   A cover for a newborn can be included from Day 1 from his date of birth, under a Group Health Insurance Policy.
5. Pre-Post Natal Expenses
   Pregnancy care consists of prenatal (before birth) and postpartum (after birth) healthcare for expectant mothers. A Group Health Policy Covers can be extended to cover Pre- Post Natal Expenses as well.
6. Waiver of Waiting Periods
   Waiting Period is a period when a certain disease is not covered under the policy and a person must wait for a certain period to pass by (say a waiting period of 1 year for a PED, which means PED will be covered under the group health insurance after one year of completion of the policy). However, the customer has the option to get all the waiting periods waived off under a Group Health Insurance Scheme.
7. Internal Congenital Disease
   An internal congenital disorder is a condition that is present from birth. Congenital disorders can be inherited or caused by environmental factors.
8. 30 Days Pre-Hospitalisation Expenses
   Medical expenses incurred for covered Hospitalisation expenses, related and prior to 30 Days of Hospitalization.
9. 60 Days Post-Hospitalisation Expenses
   Medical expenses incurred for covered Hospitalisation expenses, related and post 60 Days of discharge.
10. Day Care Procedures
    In a Group Health Insurance Policy Day Care Procedures means medical treatment which is undertaken under general or local anaesthesia in a Hospital/ Day Care Centre in less than 24 consecutive hours because of technological advancement, and which would have otherwise required a Hospitalization of more than 24 consecutive hours.
11. Daily Cash Allowance
    The insurance company usually pays a fixed amount, as specified in the Policy Schedule towards 24 hours of In Patient- Hospitalization of an Insured Member.
12. AYUSH Treatment
    Medical expenses that are incurred for in-patient treatment under Homeopathy, Ayurveda, Siddha or Unani, are subject to reimbursement.
13. Corporate Buffer
    Corporate Buffer is the amount over and above the individual or the family sum insured. The amount is set aside by the Employer for emergency situations and the decision to use this buffer is solely kept at the discretion of the HR.
14. Co Payment
    Co Payment (usually flat or % of the claim amount) refers to the amount that insured will have to bear from his own pocket.
15. Room Rent
    Room Rent means the amount charged by a hospital towards room and boarding expenses and shall include the associated medical expenses. If the Insured Member is admitted in a Hospital room where the Room Category opted or Room Rent incurred is higher than the eligible Room Category/ Room Rent as specified in the Certificate of Insurance, then, the Insured Member shall bear the ratable proportion of the total Variable Medical Expenses ( including applicable surcharge and taxes thereon) in the proportion of the difference between the Room Rent actually incurred and the Room Rent specified in the Certificate of Insurance or the Room Rent of the entitled Room Category to the Room Rent actually incurred. 

     

    

16. Health Check Up An employee can undergo a Health Check up under the Group Health Policy as per terms defined in Health Insurance Policy Schedule. This may be offered complementary or at discounted price by the Insurance Company.
17. 17) Psychiatric Treatment A Group Health Insurance can be extended to cover Psychiatric Treatments. The Insurance Company will indemnify the Insured Member for the Medical Expenses incurred towards psychiatric treatment as defined in the Policy Schedule.
18. 18) Modern Treatments Methods A Group Health Insurance can also be extended to cover Modern Treatment Method. The Insurance Company will indemnify the Insured Member for the Medical Expenses incurred towards treatment done through following modern treatment methods such as Balloon Sinuplasty, Robotic surgeries, Stem cell therapy etc as defined in the Policy Schedule.
19. 19) Lasik Surgery The Company will indemnify up to the amount specified in the Policy , for the medically necessary Expenses incurred by the Insured Member in respect of Lasik Surgery provided the power of eye is above +/- 7.5 or as specified in the Policy Schedule.
20. 20) Durable Medical Equipment The Company will indemnify up to the amount specified in the Certificate of Insurance, for the Reasonable and Customary charges necessarily incurred by the Insured Member, for procuring, fitting or hiring instruments, apparatuses or devices which are medically prescribed at the time of discharge as a medical aid such as compression stockings, hearing aids, speaking aids), standard wheelchairs crutches, orthopedic supports /braces/corrective splints, orthotics etc.

How to avail claim under a Group Health Policy?

A Claim under Group Health Insurance Policy can be availed either through Cashless or Reimbursement Mode.

Cashless Settlement

• If Hospital is Empaneled by the Insurer, patient can opt for Cashless Mode, whereby the patient gets admitted and the claim is settled directly between the Hospital and the Insurance Company or the TPA. The patient need not pay anything except the charges that are otherwise not covered under the policy
   

Things to keep in mind while availing a Cashless Service:

• Please carry ID Proof & Health Mediclaim card.
• Fill the Pre- Auth Form at Hospital carefully.
• Please take Cashless approval in advance (if possible 1 day prior to admission).
• Cashless approval takes 2-3 hours. Please inform your relationship manager or TPA, once hospital has sent the Pre Auth-Form to the Insurance Co/ TPA to avoid any gaps.
• Always be aware of your policy terms and conditions.
• In case of any confusion, speak to your relationship manager.
• Please don’t sign any declaration form without knowing its relevance.
• Please do not pay any additional amount to hospital apart from the Claim Payment after settlement.
• Please note no additional amount can be sanctioned after final discharge.

Reimbursement Settlement

• In case the insured opts for any other hospital which is not empaneled on the Insurers or the TPA’s network, the insured will have to pay the Hospital Bills from his own pocket and reimburse the same by sending all original documents to the Insurance Company for settlement.
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Document Requirements in Case of a Reimbursement Claim.

The following documents are mandatory for filing a reimbursement claim.

• Duly filled and Signed Claim Form of the Insurance Service Provider.
• Copy of TPA health Card along with valid photo id proof.
• Original Hospital Bill.
• Original Payment Receipt.
• Original Discharge Card/Summary.
• Original Investigation Reports and Pharmacy Bills along with Rx.
• Original Bills & Receipts for Investigations.
• Breakup of bills in case of single amount claimed against multiple purchase.
• Any other document which may be necessary for adjudication of claim.
• Please do not keep any document in original with you. It may call for unnecessary deductions in claim amount. Kindly keep a xerox copy for your own reference.

Permanent Exclusions

Any Claim in respect of any Insured Memberfor, arising out of or directly orindirectly due to any of the following shall not be admissible unless expresslystated to the contrary elsewhere in the Policy:

• Congenital external diseases or defects/anomalies (covered if its life threatening)
• Hospitalization for only Diagnostic Purpose, intentional self-injury, use of intoxicating drugs/ alcohol.
• Injury or disease caused directly or indirectly by nuclear weapon
• Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges, telephone charges, etc
• Cost of spectacles, contact lenses, hearing aids etc.
• Cosmetic or plastic Surgery - Expenses for cosmetic or plastic surgery or any treatment to change appearance is permanent excluded from the policy.
• Vitamins and tonics unless used for treatment of injury or disease
• Voluntary termination of pregnancy during first 12 weeks (MTP)
• Treatment taken from anyone who is not a Medical Practitioner or from a Medical Practitioner who is practicing outside the discipline for which he is licensed or any kind of self-medication.
• Unproven Treatments - Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to supporttheir effectiveness.
• Treatment received outside India.
• Change of Gender Treatments - Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.
• Any treatment related to sleep disorderor sleep apnea syndrome, generaldebility convalescence and any treatment in an establishment that is nota hospital.

Frequently Asked Questions

1. Why Group Health Insurance is important?
   A Health Insurance policy protects us from the sudden, unexpected costs of hospitalization (or other covered health events, like critical illnesses) which would otherwise make a major dent into household savings. Each of us is exposed to various health hazards and a medical emergency can strike anyone of us without any warning. In addition, Healthcare is increasingly expensive, with technological advances, new procedures and more effective medicines that have also driven up the costs of healthcare. While these high treatment expenses may be beyond the reach of many, taking the security of health insurance is much more affordable.
2. What is Group Health Insurance Policy & when it can be used?
   Health Insurance is a type of Insurance that covers your Medical Expenses. It can be used where there is at least 24 hours hospitalisation and listed day care procedures where 24 hours hospitalization not mandatory.
3. What does Hospitalization (in patient care) mean and what are the different types of Hospitalization?
   Hospitalization or In-patient Care means treatment for which the patient has to stay in a hospital for more than 24 hoursfor a covered event for treatment of certain illness. There are 2 types of Hospitalization – Planned & Unplanned. Planned hospitalisation is when you have enough time on hand to decide the hospital you want to get admitted depending upon the nature of the illness. The most essential part is to make the Insurance Company aware of the nature of illness and get approval for the same from the TPA in advance before admission. Unplanned hospitalization or an emergency hospitalization means when a patient needs emergency medical attention which cannot be managed on an outpatient basis. The insured can still avail a cashless service by informing the TPA or the insurance company.
4. What is Day Care Treatment?
   Due to medical advancement, there are many treatments which does not require complete 24 hours hospitalisation for e.g., Chemotherapy, Dialysis, Kidney Stone surgery, Cataract Surgery etc. Such Day Care Treatments are covered under Health Policy.
5. What is a Cashless Facility?
   Insurance Co. have done tie up arrangements with many of the Hospitals across India. If an employee gets admitted to any network hospital of Insurance Company, they can avail cashless facility by showing their TPA Member Id Card.
6. What is Reimbursement under Group Health Policy?
   Another mode of Claim Settlement is Reimbursement, whereby the insured settles the expenses, incurred towards his hospitalisation, directly with the hospital and later files for a reimbursement claim with the TPA or the insurance company.
7. What is the TAT for submitting reimbursement claim?
   Normally, the reimbursement claim can be filed with the TPA or the Insurance Company within 15/ 30 days from date of discharge.
8. What if the hospital is not in the network list of the insurance company?
   In case the hospital is not empanelled with the Insurance Company, you can pay to the hospital towards the hospitalisation expenses and file for a reimbursement claim from your Insurance Company.
9. What is the maximum no. of Claims which can be filed in 1 year?
   The employee can file unlimited claims up to his sum insured limits. Once his sum insured gets exhausted, he will be not able to file any further claims.
10. Is OPD & Day Care Treatment Same?
    No, OPD & Day Care are not same. Day Care Treatments (which are listed by Insurance Company) are covered under Health Policy. However, OPD is an exclusion under the policy but can be included on payment of extra premium under a Group Health Policy.
11. Can a Cashless Facility be given to a Non-Network Hospital?
    Cashless Facility can be availed only at the Network Hospital which has an tie up with the Insurance Co. If a hospital empanelled with the insurance company, then the insured will have to bear the hospitalization expenses and file for a reimbursement claim from his insurance company. Hospital Network List for each insurer varies, hence this needs to be checked with the insurer beforehand in case of a planned admission.
12. Is Health Policy valid only in India or in Foreign Land also?
    Health Policy is applicable only in India. In case an employee wants to take a policy outside Indian borders, then Travel policy must be taken which is a different product all together.
13. Is Pre-Existing Disease Covered in Health Policy?
    The Group Health Policy is generally a customised policy where features can be added basis the clients’ requirements. Pre-Existing Diseases can be from Day 1 in Group Health Insurance Policy. By pre-existing disease, we mean, any ailment which is prior to policy inception, an employee may or may not be aware about it.
14. What documents are required for Claiming under Health Policy?
    Cashless Hospitalisation – Only Insurance Mediclaim Card, Govt ID Proof, past medical records of the ailment employee is suffering from is required. Reimbursement – Claim Form, Test Reports (both X Rays & Written Reports) , Medicine Bills, Discharge Summary , Cheque Copy , Doctor Prescription , Hospital Registration Certificate etc (all documents in original).
15. Can a treatment done under Blacklisted/Cautious Hospital will be payable under Health Policy?
    No, any treatment done under Blacklisted/Cautious Hospital will not be payable under the policy. This hospital list keeps on changing for every insurer, hence please check the same with the insurer before going for a hospitalisation.
16. What role does Room Rent play in Health Policy?
    Room Rent impacts the Hospitalisation Bill. The higher the Room Rent than what is defined in your policy, more will be the % of your share in settlement of the hospital bill. Hence before Hospitalisation, we recommend checking your Room Rent Limit defined under the policy and try opting for a room within your limit. Please refrain from opting for a room higher than your defined limit. If an employee opts for a higher room rent, then the proportionate increase will be deducted on the entire bill and not only on the Room Rent part.
17. Does Health Policy Covers Diagnostic Charges like X Rays, MRI & Ultrasound etc?
    A Health Policy Covers all diagnostic tests which are connected to 24 hours hospitalisation. Any other tests which are not connected to ailment for which patient is admitted or prescribed by Doctor in OPD individually are not payable.
18. Can the insured increase the sum insured mid-year?
    Sum Insured can be changed only if the employee gets promoted during the policy period. Otherwise, it is not possible to change the sum insured during the tenure of a Group Mediclaim/ Health Policy.
19. Is medical check-up required for getting covered in Group Health Policy?
    Medical check-up is not required in any of the Group Mediclaim or a Group Health Policy.
20. Can Maternity Benefit be taken for third Child?
    Usually, Maternity Expenses can be Claimed only for first 2 Living Children or first 2 deliveries only subject to the policy terms and condition.
21. Is Covid Related Hospitalisation Payable in Health Policy?
    Yes, if a person is Covid Positive and treatment is not possible in-home isolation, hospitalisation in context to Covid Treatment is payable up to his Sum Insured limit only.
22. Can I add any dependent in the mid of year?
    Addition of dependent is allowed in the mid of year but only for Newly Wedded Spouse or new born baby under subject to the policy term and condition.
23. What is the TAT for Claim processing?
    For Cashless TAT – 2 to 4 hours and for Reimbursement Claim TAT is 15 days.

Group Health Glossary:

1. Group Health Insurance Policy – A Group Health Insurance Policy is usually taken by an Employer to cover his/ her employees. A single policy gets issued in the Employers Name and covers his entire employees.
2. Accidental/ Accident – A Group Health Insurance policy also covers In Patient Hospitalisation due to accident. An Accident is a sudden, unforeseen, and involuntary event caused by external and visiblemeans.
3. Claim means demand made in accordance with the terms and conditions of the Policy for payment of the specified Benefits in respect of the Insured Member as covered under the Policy.
4. Claimant means a person who has a valid insurance policy issued by an Insurance Company and is eligible to file a Claim in the event of any expenses incurred towards hospitalization as defined in the Policy Schedule. In a Group Health Insurance Policy, a claimant is an employee or legal dependents covered under the policy.
5. Room Boarding Expenses – The charges towards the room charged by the hospital during hospitalization. This may vary hospital to hospital.
6. Congenital Diseases means a condition which is present since birth. Internal Congenital means a condition that is not visible and is present in the body. External Congenital means a condition which is in the visible and accessible parts of the body. A Group Health Policy usually covers Internal Congenital Diseases only.
7. Critical Illnesses – Critical Illnesses means diseases that are life threatening in nature. For example – Cancer, Heart attack, Renal failure etc.
8. Cashless Claim Service – In Group Health Policy claims are settled either by cashless or reimbursement. A cashless service means a facility extended by theTPA or the Insurance Company where the treatment costs that is incurred by the insured during his hospitalisation are directly made to theHospital as per the policy terms and conditions.
9. Reimbursement – Another mode of Claim Settlement is Reimbursement, whereby the insured settles the expenses, incurred towards his hospitalisation, directly with the hospital and later files for a reimbursement claim with the TPA or the insurance company. The reimbursement claim can be usually filed with the TPA or the Insurance Company within 30 days from discharge.
10. Illness means a sickness or a disease or a pathologicalcondition leading to the impairment of normal physiological function and requires medical treatment.
11. In-patient Care means treatment for which the Insured Member has to stay in a hospital for more than 24 hoursfor a covered event.
12. Insured means a person whose name specifically appears under Insured in the policy Certificate And is a covered groupmember.
13. ICU Charges or (Intensive care Unit) Charges meansthe amount charged by a Hospital towards ICU expenses on a per day basis which shall include the expenses for ICU bed, general medical support services provided to any ICU patient including monitoring devices, critical care nursing and intensivist charges.
14. Medical Expenses means those expenses that an Insured Member has necessarily and actually incurredfor medical treatment on account of Illness or Accident on the advice of a Medical Practitioner.
15. Network Provider means the Hospitals enlisted by an Insurer, TPA to provide medical services to an Insured by a CashlessFacility.
16. Non-Network Provider means any hospital, day carecentre or other provider that is not part ofthe network.
17. OPD Treatment (Out-patient Care) is one in which the Insured visits a clinic/hospital or a diagnostic centre and treatment based on the advice of a Medical Practitioner. The patient does not get admitted like in Day Care or Inpatient Hospitalisation.
18. Road Ambulance Cover- The insurance company reimburses expenses incurred towards necessary transportation from the place of occurrence of Medical Emergency of the Insured Member, to the nearest Hospital; and/or Such Transportation is from one Hospital to another Hospital for the purpose of providing better medical aid to the Insured Member, following an Emergency.