A group health insurance plan provides risk coverage to the people who belong to a specific group. A group health insurance policy is commonly purchased by an employer for eligible employees of a company as benefit Package & in some cases may also provide cover to family members of employees. It covers hospitalization and medical expenses incurred in India only, provided period of the Hospitalization exceeds 24 hours except those which are listed in Day care treatment.
Scope of Cover
The policy covers expenses towards diseases / ailments and accidents incurred as an in-patient in a Hospital which will include:
Room, Boarding and Nurse Expenses.
Fees of Surgeon, Anesthetist, Specialists & Operation theatre Charges
The cost of diagnostic tests, medicines, blood, oxygen, appliances like pacemaker, artificial limbs and organs etc.
Alternate Treatment (AYUSH), Organ Donation Expenses
All relevant expenses incurred 30 days before and 60 days after hospitalization are reimbursable (for which a claim is payable) except in the case of maternity benefits.
Group Medi claim policy can also be extended to take care of entire family’s medical expenses I.e. Self, spouse, dependent Children and dependent parents with Family Floater under one single Sum Insured. The amount of Sum Insured “floats” over the family.
Addition In respect of new employees coverage commences from the date of joining or from 1st day of the following month. Addition of dependents shall be allowed only in the event of marriage or new born baby.
Deletion- In respect of employees whose employment, with the insured ceases, for whatever reason the coverage will automatically expire in respect of that employee and their dependents from the date of cessation of employment.
Further, the scope of cover also includes cover from 1st day of inception of the Policy, waiver of various excluded diseases in the first year, waiver of waiting period for some listed diseases (as appearing in the standard Health insurance Policy)waiver of waiting period for maternity cover, coverage for New born baby form day one ( Sum Insured Part of Mother SI) by paying additional Premium.
The insured company is the direct point of contact with the respective group health insurance provider.
Only the employer has the right to cancel the policy.
Valid for as long as the employee is part of the respective organization.
A group health policy is primarily dependent on the organization's strength; both financial and employee strength.
Pre-medical check-ups are not conducted by the Insurer.
Offer cashless facility .
Offer to cover pre and post-hospitalization charges for a specific period.
Some policies may offer maternity benefits.
Less than 24 hours hospitalization for certain procedures such as chemotherapy, eye surgery and tonsillectomy among others.
Extended cover for certain critical ailments above hospitalization benefits.
Some policies may provide cover for pre-existing diseases after payment of extra Premium.
Some policies may cover domiciliary expenses.
Some of the optional benefits include waiver of waiting period, first year Exclusions besides reimbursement of ambulance charges among others
Maternity benefit with new born baby cover: This feature covers delivery expenses (i.e. normal and caesarian) up to the Sum Insured specified in the policy. This amount is included within the total sum insured.
Corporate Buffer : A special privilege extended by paying additional Premium wherein the Sum insured can up topped up through the sum insured of corporate buffer in cases where the claim exceeds the sum insured of the employee.
Cover for certain critical ailments above hospitalization benefits
Cover for pre-existing diseases
Cover for domiciliary expenses.
Waiver of waiting period, first year Exclusions, reimbursement of ambulance charges etc
Minimum age of entry: Consider correcting as Even a baby can be covered from day one within the overall Maternity Limit (subject to admissibility of the Maternity claim).
In order to be eligible for group health insurance, a company should have minimum group of 50 individuals.
Minimum age of entry: A baby can be covered from day one within the overall Maternity Limit (subject to admissibility of the Maternity claim).
Naturopathy or other forms of local medication
Intentional self-injury / injury under influence of alcohol, drugs, Diseases such as HIV or AIDS
Diseases existing from the time of birth (Congenital diseases)
Cost of spectacles, contact lenses and hearing aids.
Dental treatment or surgery of any kind unless requiring hospitalization.
Charges incurred at Hospital or Nursing Home primarily for diagnostic without any treatment.
Expenses on vitamins and tonics unless forming part of treatment for disease or injury as certified by the medical practitioner.
Cosmetic, aesthetic, treatment unless arising out of accident.
Routine medical, eye and ear examinations
Treatment of mental illness