What is Covered Under Group Health Insurance and How Does it Work?

1. Introduction: Group health insurance is a type of health insurance that is offered to a group of employees under a single master policy. The group health insurance is generally taken by the employer for their employees as a part of the employee benefits. Group health insurance premium is paid by the employer and the benefits of it are passed on to the employees. The coverage and the other terms and conditions required in the group health insurance will be decided by the premium payer i.e. employer. 

Group health insurance policy is normally offered to the employees of an organization, if needed the same coverage can be extended to the family of the employees. In certain cases the parents/ parents-in-law of the employees are also covered under the group health insurance. Most of the organizations provide coverage for parents on payment of additional premium which is either deducted from the salary of the employees or paid upfront by the employees. The members under the group health insurance policies can even extend their coverage by purchasing the top up health insurance plans which come with a certain deductible amount. For best top up insurance plans to be purchased with the group health insurance policy please book a call with Ethika insurance. We at ethika insurance have a team of group health insurance experts who strive to bring employee happiness element in the group health insurance policies. 

2. Features of Group Health Insurance Policy: Group health insurance policies are tailor made. There is no specific format in which the policies should be designed. The group health insurance policy can be customized as per the needs and requirements of the employer. Below are the features of group health insurance policy:-

1. Inpatient hospitalization: Inpatient hospitalization is a condition where the insured patient is admitted to the hospital for more than 24 hours for the purpose of treatment. The patient admitted under the inpatient category has to undergo treatment for at least 24 hours, which may even extend depending on the type of treatment. The maximum coverage under the inpatient hospitalization is the sum insured mentioned under the policy. In most of the cases where the patient is admitted under inpatient, high level of monitoring and in-depth observation is required. 

Certain illnesses or diseases such as Heart attack, flu, burns etc. require the patient to be admitted for more than 24 hours under the inpatient section. Certain surgeries and operations also require inpatient admission. 

2. Day care treatment: Day care treatment is a condition in which the insured patient can undergo treatment and be discharged from the hospital within 24 hours and therefore doesn’t require inpatient hospitalization. Due to the advancement in technology most of the procedures are carried out in less than 24 hours which comes under the day care treatment section. These include chemotherapy, radiation, dialysis, cataract etc. Every year there would be new day care treatments that would be added and it is important to check whether your insurance company is offering the same or not. 

For example, knee replacement surgery is done and patients would be discharged within 8-12 hours of the day which doesn’t require inpatient hospitalization and comes under the daycare treatment. Each insurance company would have a list of day care procedures that are covered under the group health insurance policy. It is important for the employer to find out the list of daycare procedures before taking the group health insurance policy. This is where Ethika insurance would come into picture by providing the details of day care procedures from all the insurance companies and the customer can decide the best group health insurance policy. The maximum coverage under the group health insurance policy would be the sum insured provided to the employee.

3. Ayush: Alternate treatments such as Ayurveda, Yoga, Unani, Sidha and Homeopathy are covered under the group health insurance policy. The maximum coverage under the alternate treatments would be the sum insured available under the policy terms and conditions. AYUSH treatments are trusted by millions of people across the country and are considered as the traditional health and wellness treatments that are cost-effective as well as have miniscule side effects. 

The claim under AYUSH treatments is accepted only if the patient is admitted as an inpatient where the duration of stay in the hospital is for at least 24 hours. The alternative treatment taken in any Government recognized or accredited by the concerned body will be considered by the insurance company. The maximum coverage available for any hospitalization under the AYUSH cover varies from one insurance company to another.  

4. OPD: OPD includes out-patient treatment taken by the insured patient which doesn not require either the inpatient admission or day care admission in the hospital. OPD is a treatment wherein certain types of illness or diseases are treated upon the advice of a medical practitioner. Out-patient treatment is basically consultation with the medical practitioners regarding the treatment to be undertaken. OPD claims are generally settled on a reimbursement basis where the insured customer has to first avail the service, pay the claim bill to the hospital and then submit the original documents to the insurance company for claim processing. 

5. Accidental Dental treatment: Normally any treatment related to dental is not covered in the health insurance policies. Dental treatment is considered as cosmetic treatment that is used to enhance beauty. Therefore accidental dental treatments are covered under the group health insurance policy in which the dental treatment required due to an accident. The coverage for the accidental dental treatment varies from one insurance company to another. The accidental dental treatment covers the surgeries or operations to be done by the treating hospital.

6. Pre-existing diseases: There are certain types of waiting periods in health insurance policies in which the insured can make a claim only after satisfying the waiting period under the policy. 

1. Initial waiting period or 30 day waiting period is the time in which the insured customer has to wait for a period of 30 days after taking the policy to make any claim. This clause is applicable only for new retail health insurance policies taken and not for the renewal or group health insurance policies. Hospitalization due to accidents is exempted from the initial waiting period. 
2. Specific waiting periods may vary from 1 year to 3 years during which the customer cannot claim for certain illnesses or diseases as specified in the policy period. There are certain illnesses such as knee replacement, cataract, kidney stone removal etc. which can be claimed only after satisfying the specific waiting period. This clause is not applicable in group health insurance policies and the customers can claim anytime after taking the group health insurance policy.
3. Pre pre-existing waiting period is the period in which the customer cannot make a claim for any pre existing diseases that were declared before the inception of the policy. The pre-existing waiting period varies from 1 year to 4 years. Any condition of the insured that existed prior to taking the health insurance policy is considered as pre-existing disease. The pre-existing waiting period is not applicable in group health insurance policies.  
4. Maternity Waiting period is the time period in which the insurance company will not settle any maternity related claim under the health insurance policy. The maternity waiting period ranges from 9 months to 2 years in certain health insurance policies. In group health insurance policies maternity waiting period can be exempted. 

7. Maternity & new born baby cover: Maternity cover includes the delivery and other related expenses incurred by the insured patient. Any kind of expenses incurred on newborn babies are also covered under the group health insurance policy. The medical expenses of the newborn babies are covered up to a period of 90 days after which the baby can be added to the group health insurance policy on payment of additional premium. The pre and post maternity related hospitalization expenses are also covered under the group health insurance policy. The hospitalization charges include room rent, nursing charges, surgeon charges, anesthetic consultation, emergency ambulance charges etc. 

The main advantage of group health insurance policy is that there would be no maternity waiting period. The maternity related expenses can be claimed immediately after taking the group health insurance policy. 

8. Ambulance cover: Emergency ambulance cover provides a certain amount to the insured patient for utilizing ambulance to and from hospital. The ambulance charges are paid under the hospitalization expenses incurred by the patient to undergo treatment for any illness or disease or accident. The ambulance charges may range from Rs.500 to Rs.3000 depending on the option exercised by the employer at the time of taking the group health insurance policy. 

The ambulance charges incurred by the patient customer for traveling to and from the hospital is paid by the insurance company under the group health insurance policy. The maximum payable amount under the ambulance cover would be decided by the employer at the time of taking the health insurance policy. 

9. Pre & Post hospitalization expenses: Pre hospitalization expenses are the medical costs incurred by the insured before getting admitted in the hospital as an inpatient while the post hospitalization expenses are the medical costs incurred by the patient after discharge from the hospital. The minimum number of days for which the pre and post hospitalization expenses are 30 days and 60 days which are paid by the insurance company. 

For the insured customer to claim under pre and post hospitalization, inpatient admission in the hospital is mandatory. Pre and post hospitalization expenses are the medical costs incurred by the insured patient for diagnosis tests, followup tests etc. which are required as a part of hospitalization. 

10. Room rent and nursing expenses: Room rent is payable under the group health insurance policy for inpatient hospitalization. If the insured customer is admitted to the hospital as an inpatient, then the room rent expenses would be paid by the insurance company up to the sum insured available. Typically the room rent limit in group health insurance policies would be 1-2% of the base sum insured or up to a limit of Rs.5k or Single private room. It is important to note that all the expenses under the health insurance claim would be paid depending on the type of room selected by the customer. If the patient takes a room with rent higher than the limit, then all the other charges would also be reduced proportionately. 

Room rent limits can become an issue if the patient is selecting a higher limit room at the time of admission to the hospital. For more understanding on this issue please book a call with us now to get advice from our group health insurance experts at Ethika insurance. 

11. Corporate Buffer: Corporate buffer is the extra sum insured in a group health insurance that is maintained by the organization/ employer. In simple words, a corporate buffer is the health insurance coverage available to the employer who in turn can distribute it to the employees in need. Corporate buffer caters to the members of a group health insurance policy in times of emergencies when the base sum insured is exhausted. The employer can transfer a part of the corporate buffer to the employees who are in need after the exhaustion of the basic sum insured. The amount of corporate buffer that should be taken is decided by the employer at the time of taking the group health insurance policy. 

Corporate buffer works with the same terms and conditions available under the group health insurance policy. The corporate buffer comes into picture only after the base sum insured is exhausted by the employee and there is a requirement for extra sum insured. The allocation of corporate buffers to the employees is entirely up to the employer. The corporate floater can be utilized by any of the family members of the employee covered under the group health insurance policy. 

3. Working Model: The working model of the group health insurance policy from start to end is explained below:- 

1. Discussion: The first stage in the group health insurance policy working model is to have a discussion with the insurance broker regarding the coverage required, plans available and pricing. The organization should give clear instructions to the insurance broker regarding the coverage required under the group health insurance policy. If the organization is already having a group health insurance policy, then it should mention if the renewal is to be done at existing terms and conditions or new terms and conditions are required. 

We at Ethika insurance listen and understand the needs of our customers and explain the coverages available under the health insurance policies in addition to the value addition provided from our end. Employee happiness is the main element which is missing in most of the health insurance policies that are covered by us. 

2. Data Collection: The next step is to collect the data pertaining to the group health insurance policy. The data to be collected for new customer as well as existing customer is given below:-

i) Previous year policy copy which contains the details of coverage and other terms and conditions

ii) Active member list of employees to be included in this year Group health insurance policy

iii) Claims data for the last year and Claims analysis report.

The data collected from the customer will be analyzed by the insurance broker and quote requests would be prepared and sent to the insurance companies for further processing. It is important to give the correct data to the insurance broker in a single shot so that the to and fro can be reduced. 

3. Quote Submission: The next step is where the insurance broker would collect quotations from different insurance companies and share the same with the client. The premium would differ among the insurance companies but the coverage would be similar to that requested by the customer. Once the customer receives the quotes, the best quote can be finalized after discussion with the insurance broker. It is here where the expertise of Ethika insurance broker would come handy to the customer as we deal with all the insurance companies and know the best insurance company that can match the needs and requirements of the customers. 

4. Policy issuance & Health cards distribution: The next step is to accept the quote from the best insurance company and then pay the required premium. After the premium is paid by the customer, the insurance broker co-ordinates with the insurance company to issue the group health insurance policy. Once the group health insurance policy is issued, the same would be shared with the customer. After the policy is issued, health cards either in physical or electronic mode will be shared with the customer to distribute among the employees. 

The health cards can be utilized by the employee to avail cashless health insurance services at any network hospitals. Network hospitals are the hospitals that are empanelled by the insurance companies to provide cashless claim settlement facility. It is advisable to carry the health cards at all times so that the same can be shown to the hospital in case of an emergency admission. 

5. Additions/Deletions: Every organization has a set of people leaving and joining which necessitates changes in the group health insurance policy. Additions are done when new employees join the organization while the deletions are done when the employees leave the organization. Addition of members would require premium to be paid on a pro rata basis or short period basis by the employer while the deletion of members would result in refund of premium by the insurance company. The additions and deletions should be intimated to the insurance company within 45 days of occurence of the event. 

The employer can maintain a CD account with the insurance company where the premium would be taken for additions and refunded in case of deletions. Automatic additions and deletions would take place if there is sufficient amount in the CD account. 

6. Cashless Claim Settlement: Cashless claim settlement facility is where the insured customer can get treated in a network hospital and the claim would be settled by the insurance company directly to the hospital without any payment from the customer’s end. Network hospital is the hospital that is empanelled by the insurance company to provide cashless claim settlement service to its customers. The network hospitals have pre-fixed rates for every service. The insurance company would agree on a fixed amount with the hospitals to benefit the customers. 

Cashless claim settlement is the most preferred way of claim settlement as the customer need not pay from his pocket. The insurance company would directly settle the claim to the hospital. Most insurance companies approve the cashless claim settlement request within 2 hours of notification. 

7. Reimbursement Claim settlement: Reimbursement claim settlement is a process in which the customer has to pay the hospital bill first and then claim from the insurance company after submitting the required documents. If the customer is getting treated in any of the non network hospitals, then the reimbursement option should be exercised by the customer. 

The reimbursement of claims is done within a period of 15-20 days from the date of submission of the last required document. Reimbursement claim settlement should be availed only when there is no other option available to the insured. 

4) Documents required for Claim Settlement: There are certain documents which are required at the time of claim settlement. These documents are mandatory to settle the claim under the group health insurance policy.

1. Health card or the policy copy
2. Duly filled and signed claim intimation form
3. KYC documents 
4. Doctor’s prescription stating the need for hospitalization
5. Doctor’s prescription advising to undergo a treatment, medicines, procedures etc.
6. Original pharmacy bills
7. First information report, if applicable
8. Discharge summary

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These documents are required only if the reimbursement option is selected by the insured customer. If the customer opts for a cashless option, then only the claim form needs to be filled and signed in addition to providing the KYC documents to the hospital. The remaining process would be taken care of by the hospital.